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.

Answer and Explanation

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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Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A Reason:
Aspiration is a significant risk for clients with acute alcohol intoxication due to an impaired gag reflex. Alcohol can depress the central nervous system, leading to a decreased level of consciousness and a diminished gag reflex, which increases the risk of aspiration of gastric contents into the lungs.

Choice B Reason:
Impaired coordination and judgment are common in acute alcohol intoxication, increasing the risk of injury. Alcohol affects the cerebellum, the part of the brain that regulates coordination and balance, as well as the frontal lobes, which are responsible for judgment and decision-making.

Choice C Reason:
Alcohol is metabolized by the liver, and excessive alcohol intake can lead to alcohol toxicity and liver impairment. Acute alcohol intoxication can cause hepatic steatosis, alcoholic hepatitis, and even acute liver failure in severe cases.

Choice D Reason:
Dizziness and an unsteady gait are direct effects of alcohol's impact on the vestibular system and the brain's ability to process spatial information, leading to an increased risk of falls.

Choice E Reason:
Alcohol intoxication can impair immune function, making the client more susceptible to infections. Alcohol disrupts immune pathways in complex ways, which can impair the body's ability to defend against infections

A. A: "I'm glad you called, and I want to send an ambulance to help you." B. B:"You must have been feeling pretty depressed to do that." C. C:"Were you trying to kill yourself by taking an overdose?" D. D:"Do you know how many pills were in the bottle?"

Correct Answer is A

Explanation

Choice A Reason:
In a situation where a client has ingested a potentially lethal amount of medication, immediate medical intervention is crucial. Amitriptyline is a tricyclic antidepressant, and overdose can lead to life-threatening conditions such as cardiac arrhythmias, severe hypotension, and seizures. The nurse's priority is to ensure the safety of the client by sending an ambulance. This response also acknowledges the client's cry for help and initiates prompt action.

Choice B Reason:
While it's important to recognize the emotional state of the client, this response does not address the immediate medical emergency. The client's safety is the priority, and while their feelings are valid, this choice does not facilitate the urgent care needed.

Choice C Reason:
Asking if the client was trying to commit suicide can come across as judgmental and may close off communication. It's essential to maintain an open line of communication and focus on getting medical help rather than determining intent at this critical moment.

Choice D Reason:
Knowing the quantity of medication ingested can be useful information for medical professionals; however, it is not the most immediate concern in a crisis situation. The first response should be to ensure that medical help is on its way.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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