A nurse is teaching a client who has alcohol use disorder about disulfiram. Which of the following client statements indicates an understanding of the teaching?

Rationale for correct choices

• obtain IV access: The client’s blood pressure has dropped significantly from 90/50 mm Hg to 76/45 mm Hg, and heart rate is elevated, indicating hypovolemic shock likely due to gastrointestinal bleeding. Establishing IV access is critical to provide rapid fluid resuscitation and allow administration of medications or blood products as needed.

• prepare to administer IV fluids: With hypotension and tachycardia, the client requires fluid resuscitation to restore circulating volume and improve perfusion prior to undergoing an invasive procedure like endoscopy. IV fluids will help stabilize hemodynamics and reduce the risk of complications during the procedure.

Rationale for incorrect choices

• recheck the client’s oxygen saturation: The client’s oxygen saturation is stable at 98% on room air, indicating adequate oxygenation. While monitoring is important, it does not address the more urgent issue of hypovolemia.

• call the surgical suite to notify that the client is arriving STAT: Notifying the suite is necessary for scheduling, but immediate intervention to stabilize the client’s hemodynamic status takes precedence over notification. Transport should not occur until the client is stabilized.

• place the client in a supine position with feet elevated: While this may provide temporary support for hypotension, it does not treat the underlying hypovolemia. IV access and fluid resuscitation are more effective and urgent interventions.

• check an ECG: Although ECG monitoring may be helpful in hypotensive clients, it is not the immediate priority over fluid resuscitation and IV access.

• check an arterial blood gas: ABG analysis is not immediately necessary because the client’s oxygenation is adequate and the priority is stabilizing circulation.

• transport the client for endoscopy: Transporting the client before hemodynamic stabilization would be unsafe given hypotension and tachycardia. Resuscitation must occur prior to the procedure.

Rationale:

A. Initiate one-to-one observation for the client: One‑to‑one observation is essential for safety when a client expresses risk for self‑harm, but the nurse must first assess the content of the hallucinations to determine the immediacy and severity of the risk. Understanding what the voices are saying guides the urgency of interventions and the level of monitoring required.

B. Turn on soft music to distract the client from hearing voices: Distraction techniques can help clients manage hallucinations, but they are not appropriate as an initial action when the client is reporting commands related to self‑harm. The priority is to gather critical assessment data before attempting coping strategies that may not address imminent danger.

C. Ask the client what they are hearing: Assessing the content, tone, and intent of the hallucinations is the first priority because command hallucinations can pose significant danger. Asking directly helps the nurse determine whether the client has an immediate plan or intent to act, which guides safety precautions and necessary interventions.

D. Refer to the hallucination as if it were real: Reinforcing hallucinations can worsen the client’s disorientation and increase distress. The nurse should maintain therapeutic boundaries by acknowledging the client’s experience without validating the hallucination, while also performing an immediate assessment of the risk of self‑harm.