A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

The correct answer is choice A: "Assess the client's need for assistance with ADLS."

Choice A rationale:

Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.

Choice B rationale:

Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.

Choice C rationale:

Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.

Choice D rationale:

Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.

Choice A rationale:

Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.

Choice B rationale:

Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.

Choice C rationale:

Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.

Choice D rationale:

Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.