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. Encouraging descriptions of perceived failures may further exacerbate the client's poor self- esteem and is not a therapeutic intervention.
B. While setting limits is important in managing behavior, it may not directly address the underlying issue of poor self-esteem.
C. Providing activities that can be accomplished can help boost the client's confidence and self- esteem.
D. Teaching aggressive communication skills is not appropriate and may contribute to further negative self-perception.

A. A decreased level of consciousness with intermittent periods of hypervigilance. B. A slow onset of confusion and agitation. C. A decrease in the client's output and vital signs. D. The symptoms have lasted longer than a month.

Correct Answer is A

Explanation

A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.

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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

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?

Correct Answer is C

Explanation

A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

Correct Answer is A

Explanation

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