The nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal symptoms. Which of the following should be the priority action by the nurse?
Support the client's attempt to rebuild damaged interpersonal relationships.
Teach the client about the effects of alcohol dependence and the need for rehabilitation.
Teach the client alternative strategies for managing anxiety.
Prepare to administer Ativan as ordered.
The Correct Answer is D
Choice A reason:
Supporting the client's attempt to rebuild damaged interpersonal relationships is an important long-term goal in the recovery process. However, it is not the immediate priority when a client is experiencing acute withdrawal symptoms, which can be life-threatening.
Choice B reason:
Educating the client about the effects of alcohol dependence and the need for rehabilitation is crucial for long-term recovery and preventing relapse. Nevertheless, during acute withdrawal, the priority is to manage the physical and psychological symptoms safely.
Choice C reason:
Teaching the client alternative strategies for managing anxiety is a valuable part of therapy and helps in long-term coping. However, during acute withdrawal, the client may not be able to learn or apply these strategies effectively due to the severity of their symptoms.
Choice D reason:
Preparing to administer Ativan as ordered is the priority action. Ativan (lorazepam) is a benzodiazepine commonly used to treat alcohol withdrawal symptoms. It helps to prevent seizures, reduce agitation, and manage other withdrawal symptoms. During the acute phase of alcohol withdrawal, maintaining physiological stability and ensuring the client's safety are the primary concerns.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Walking with the client at a gradually slower pace is a therapeutic technique that can help reduce anxiety. It allows the nurse to provide a calming presence and support while also helping to decrease the client's physical agitation in a controlled manner. This approach is non-confrontational and can be very effective in managing acute anxiety symptoms.
Choice B reason:
Having a staff member escort the client to her room might seem like a reasonable option, but it could be perceived as punitive or isolating, especially if the client is not posing a risk to themselves or others. It may also escalate the client's anxiety by making them feel confined or punished.
Choice C reason:
Instructing the client to sit down and stop pacing is not advisable as it may come across as dismissive of the client's distress. It could also increase the client's anxiety by making them feel that their coping mechanism (pacing) is not acceptable, which could lead to increased agitation or resistance.
Choice D reason:
Allowing the client to pace alone until physically tired is not the best option as it does not provide any direct support or intervention from the nurse. While pacing may be a self-soothing behavior, it does not address the underlying anxiety and could potentially lead to physical exhaustion without any emotional relief.
Correct Answer is A
Explanation
Choice A reason:
Alcohol use disorder (AUD) is associated with various workplace problems. Individuals with AUD may experience a decline in their work performance due to cognitive, emotional, and behavioral impairments caused by alcohol use. This can manifest as frequent tardiness, absenteeism, and a decrease in productivity. Moreover, alcohol use can lead to workplace injuries and conflicts, which further affect an individual's ability to perform their job effectively. Therefore, asking about the impact of alcohol use on work performance can provide insights into the extent of the disorder's effect on the client's psychosocial behaviors.
Choice B reason:
The age at which an individual begins drinking alcohol is a significant factor in the development of AUD. Studies have shown that early onset of drinking increases the risk of developing alcohol dependence later in life. While this information is valuable for understanding the client's history with alcohol, it does not directly address the current impact of alcohol use on their psychosocial behaviors.
Choice C reason:
Previous treatment for substance use disorder can indicate the severity of the client's condition and their history of seeking help. Treatment history can also reveal patterns of relapse or recovery, which are important in the management of AUD. However, this choice does not specifically inquire about the current psychosocial impact of alcohol use.
Choice D reason:
Mental health disorders often co-occur with AUD, and the presence of such disorders can exacerbate the psychosocial impact of alcohol use. While it is crucial to understand the client's overall mental health, this question does not focus on the specific effects of alcohol use on work performance and other psychosocial behaviors.
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