A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Identify the use of defense mechanisms.

Prevent the client from harming herself or others.

Support the client's coping skills.

Answer and Explanation

The Correct Answer is B

Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.

Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.

Choice C, supporting the client's coping skills, is not a priority intervention.

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Correct Answer is D

Explanation

Validation. Validation is a therapeutic technique that involves acknowledging and accepting the feelings and emotions of the person with dementia, even if they are not based on reality. Validation helps to reduce agitation and anxiety and promotes dignity and respect.

The other choices are not correct for the following reasons:

Remotivation is a technique that aims to stimulate the person's interest in the present and future, by providing factual information and encouraging participation in activities. Remotivation may not be appropriate for someone who is agitated and living in the past.

Orientation to reality is a technique that involves correcting the person's misperceptions and confusions, by providing factual information about time, place, and identity. Orientation to reality may increase agitation and frustration and may damage the person's self-esteem.

Guided imagery is a technique that involves using mental images to promote relaxation and well-being. Guided imagery may not be effective for someone who has difficulty with attention, concentration and memory.

A. "It must be very difficult for you to see your wife in pain." B. "I wish there was more that I could do to relieve your wife's pain, too." C. "I'm sure your wife will begin to feel better soon." D. "We're doing everything we can to keep your wife comfortable."

Correct Answer is A

Explanation

Answer: A

Rationale:

A) "It must be very difficult for you to see your wife in pain.": This response acknowledges the partner's feelings and provides emotional support. It shows empathy and validates the partner's experience, helping to build rapport and trust between the nurse and the family member.

B) "I wish there was more that I could do to relieve your wife's pain, too.": While this response expresses sympathy, it might unintentionally convey a sense of helplessness or inadequacy on the part of the nurse, which could increase the partner's anxiety or frustration.

C) "I'm sure your wife will begin to feel better soon.": This response is intended to be reassuring, but it can come off as dismissive of the partner's current concern and may not address their immediate emotional needs. It also makes a promise that the nurse cannot guarantee.

D) "We're doing everything we can to keep your wife comfortable.": This response provides factual information about the care being provided, but it does not address the partner's emotional distress. It focuses on the actions of the healthcare team rather than acknowledging the partner's feelings.

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A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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