The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

orient to reality.

identify social supports.

replace fluids.

apply restraints.

Answer and Explanation

The Correct Answer is C

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

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Correct Answer is D

Explanation

D. Engaging in play activities can indicate that the child is focusing their energy positively and is able to engage with their environment in a constructive way. Play can also serve as a therapeutic tool that helps children with ADHD improve their attention, reduce hyperactive behavior, and learn social skills.
A. Manipulative behaviors may not be directly related to the core symptoms of ADHD, but they can be present in some children with ADHD as a way of coping with difficulties in attention and impulse control.
B. Redirection of violent behaviors involves guiding the child towards more appropriate and non-violent ways of expressing their emotions and frustrations. Monitoring for successful redirection of violent behaviors would indicate progress in improving impulse control and emotional regulation.
C. Withdrawal when frustrated is not a desired outcome for a child with ADHD. Instead, the goal is typically to help the child develop coping strategies to manage frustration constructively and remain engaged in activities.

A. assess the client's airway and breathing. B. assess the client's gag reflex. C. call the physician immediately. D. document this as normal findings and reassess in half an hour.

Correct Answer is A

Explanation

A. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.

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The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

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Naxlex Comprehensive Predictor Exams

A 7-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. The nurse should monitor for which desired outcome?

Correct Answer is D

Explanation

The nurse is caring for a client after an endoscopy. The client is lethargic and not responding to verbal commands. The priority nursing action is to:

Correct Answer is A

Explanation

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