A nurse is reviewing the day 5 vital signs and nurses' notes.

Exhibits

A nurse is evaluating the client's response to treatment.

Select the 4 findings that indicate the client is progressing with their plan of care.

Participation in group therapy

Movement through the stages of grief

Client resolves to limit alcohol consumption

Appetite

Cognition

Vital signs

Answer and Explanation

Correct Answer : A,B,E,F

A.   Participation in group therapy - This indicates the client's engagement in therapeutic interventions, suggesting progress in addressing their alcohol use disorder and coping with grief.
B.   Movement through the stages of grief - Progress in processing grief is a positive sign of emotional healing and adjustment.
C.   Client resolves to limit alcohol consumption - While resolution to limit alcohol consumption would be an ideal outcome, there is no specific indication in the scenario that the client has made this resolution.
D.   Appetite - Although improvement in appetite would be a positive sign, there is no specific mention of the client's appetite in the provided information, so it cannot be assumed that this finding indicates progress in the client's plan of care.
E.   Cognition - Improvement in cognition suggests a reduction in the effects of alcohol intoxication or withdrawal, indicating progress in treatment.
F.   Vital signs - Stable vital signs within normal range suggest physiological stability and potentially a positive response to treatment.

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Correct Answer is ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

A. "How has this impacted your life?" B. "Are you okay with not being able to do some things you used to do?" C. "Is anyone available to assist you with your hygiene?" D. “Why do you think this has happened?"

Correct Answer is A

Explanation

A. This question assesses the client's perception of the impact of the stroke on their life, providing insight into their coping abilities and emotional response.

B. This question addresses acceptance but may not fully assess the client's coping strategies or emotional response to the stroke.
C. This question addresses practical assistance with hygiene tasks but does not directly assess coping mechanisms.
D. This question focuses on the cause of the stroke rather than the client's coping abilities or emotional response.

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A nurse is reviewing the day 5 vital signs and nurses' notes. Exhibits A nurse is evaluating the client's response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

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A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

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Correct Answer is A

Explanation

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A nurse is reviewing the day 5 vital signs and nurses' notes.

Exhibits

A nurse is evaluating the client's response to treatment.

Select the 4 findings that indicate the client is progressing with their plan of care.