A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

Hypertension

Headache

Insomnia

Tinnitus

Answer and Explanation

The Correct Answer is B

A. Hypertension:
Disulfiram does not typically cause hypertension as an adverse effect. However, consuming alcohol while taking disulfiram can lead to a range of cardiovascular effects, including hypotension rather than hypertension.

B. Headache:
Consuming alcohol while taking disulfiram can result in a severe and rapid onset of symptoms known as the disulfiram-alcohol reaction. Headache is a common symptom of this reaction, along with flushing, nausea, vomiting, and palpitations. Therefore, monitoring for headaches is essential in clients taking disulfiram who report alcohol ingestion.

C. Insomnia:
Insomnia is not a commonly reported adverse effect of disulfiram. The disulfiram-alcohol reaction primarily involves physical symptoms rather than disturbances in sleep patterns.

D. Tinnitus:
Tinnitus, or ringing in the ears, is not a typical adverse effect of disulfiram. However, disulfiram can cause a range of neurological symptoms as part of the disulfiram-alcohol reaction, but tinnitus is not commonly reported.

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Correct Answer is D

Explanation

A. Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment. Examples include MRSA, C. difficile, and other multidrug-resistant organisms.
B. Airborne precautions are used for infections transmitted by small droplets that remain suspended in the air and can be inhaled. Examples include tuberculosis (TB), measles, and chickenpox (varicella).
C. Protective environment precautions are typically used for clients with compromised immune systems, such as those undergoing stem cell transplants, to protect them from environmental pathogens.
D. Droplet precautions are used for infections transmitted by large respiratory droplets that can travel up to approximately 3 feet. Examples include bacterial meningitis, influenza, and pertussis. Therefore, the nurse should initiate droplet precautions for the school-age child with bacterial meningitis.

A. The nurse wears an N95 respirator when performing client care. B. The nurse places the client on airborne precautions. C. The nurse ensures the client's room maintains a positive airflow. D. The nurse has the client wear a mask for transport to radiology.

Correct Answer is C

Explanation

A. The nurse wears an N95 respirator when performing client care: Measles is highly contagious and spreads through respiratory droplets. Wearing an N95 respirator provides appropriate respiratory protection for the nurse when caring for a client with measles. This action is appropriate and does not require intervention by the charge nurse.
B. The nurse places the client on airborne precautions: Measles is transmitted via airborne droplets, so placing the client on airborne precautions is necessary to prevent the spread of the disease to others. This action is appropriate and aligns with infection control guidelines.
C. The nurse ensures the client's room maintains a positive airflow: Positive airflow can potentially contribute to the spread of airborne pathogens outside the room, increasing the risk of transmission to others. For clients with airborne infections like measles, negative airflow rooms are required to minimize the risk of transmission to healthcare workers and other clients. Therefore, the charge nurse should intervene and correct this action.
D. The nurse has the client wear a mask for transport to radiology: Having the client wear a mask during transport helps minimize the spread of infectious droplets to others in the facility. This action is appropriate and aligns with infection control measures for airborne precautions

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A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?

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