A nurse on an inpatient mental health unit is admitting a client.

Exhibits

The nurse is reviewing the client's medical record at 0830 on day 2 of admission.

For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client's condition.

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. Oxygen saturation is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
B. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Therefore, assessing the client's blood pressure is essential to monitor for potential hypertensive effects.
C. Bowel sounds are not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
D. Pupil response is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.