The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Administer thiamine intramuscular (IM)

Assist the client with personal hygiene needs

Place the client on continuous observation

Explain milieu therapy

Answer and Explanation

The Correct Answer is B

A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.

B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.

C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.

D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.

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Correct Answer is C

Explanation

A. Loss of appetite can be a symptom of PMDD, but it is not the primary manifestation.
B. Insomnia can be a symptom of PMDD, but it is not the primary manifestation.
C. Emotional lability, or rapid and intense mood swings, is a primary manifestation of PMDD.
D. Anxiety can be a symptom of PMDD, but it is not the primary manifestation.

A. Label the bathroom door. B. Take the older adult to the bathroom hourly. C. Place the older adult in disposable adult briefs. D. Limit the intake of oral fluids to 1000 mL/day.

Correct Answer is A

Explanation

A. Labeling the bathroom door can provide a visual cue to help the older adult locate the bathroom, which may reduce episodes of incontinence.
B. Taking the older adult to the bathroom hourly is a good strategy, but it may not always be feasible or effective in preventing accidents.
C. Using disposable adult briefs may be necessary at times, but it should not be the first line intervention.
D. Limiting oral fluids to 1000 mL/day may lead to dehydration and is not an appropriate intervention for addressing incontinence.

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The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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