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.
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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Related Questions
Correct Answer is C
Explanation
The parents report that the child injured herself by falling off the couch.
A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.
Choice A is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.
Choice B is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.
Choice C is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones.
Choice D is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.
Correct Answer is D
Explanation
If suspicion of abuse exists then reporting is mandatory.
Choice A is incorrect because civil liability does not depend on whether the abuse can be proven or not, but on whether the report was made in good faith or not.
Choice B is incorrect because evidence of abuse does not need to be collected prior to reporting, but only reasonable suspicion of abuse.
Choice C is incorrect because reporting is not voluntary for healthcare workers, but mandatory by law.
Choice D is correct because if suspicion of abuse exists then reporting is mandatory for any person, agency, organization, or entity with direct knowledge of child abuse or neglect.
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