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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Turn on a dance video so the client can burn off excess energy.
This intervention might help the client to channel their energy in a safe and controlled manner. However, it might also reinforce the manic behavior, which could be counterproductive in the long term.
Choice B: Take the client to a calm environment and offer snacks.
This intervention could help to distract the client from their manic behavior and provide them with a calming and grounding experience. Offering snacks could also help to stabilize their energy levels.
Choice C: Offer the client a low-calorie snack in return for stopping the behavior.
This intervention could be seen as a form of behavioral reinforcement. However, it might not be effective if the client is not motivated by food or if they perceive it as a form of manipulation.
Choice D: Observe the client closely for the development of aggressive behavior.
This intervention is crucial for ensuring the safety of the client and others in the unit. If the client's behavior escalates to aggression, the nurse would need to take immediate steps to de-escalate the situation and protect everyone involved.
Correct Answer is ["A","B","E"]
Explanation
Choice A reason:
A necklace can pose a risk for clients with suicidal tendencies as it can be used to inflict self-harm. In an acute mental health unit, it is crucial to remove any items that could potentially be used in another suicide attempt. The nurse should ensure that the environment is safe and free from objects that could be used for hanging or strangulation.
Choice B reason:
Lace-up tennis shoes have laces that can be removed and used by the client to harm themselves. It is a standard safety precaution in mental health units to remove any items with strings or laces, such as belts, drawstrings, or shoe laces, to prevent their use in self-harm or suicide attempts.
Choice C reason:
Nylon ankle socks are generally considered safe and do not typically need to be removed. They do not pose a significant risk for self-harm. Therefore, the client can keep these for personal comfort and hygiene.
Choice D reason:
Cotton underwear is a basic necessity and does not present a risk for self-harm. It is important for the client's dignity and hygiene to have access to personal undergarments while in the mental health unit.
Choice E reason:
A glass-framed picture, while sentimental, poses a risk due to the glass, which can be broken and used to inflict self-harm. For safety reasons, any items made of glass or other breakable materials should be removed from the client's access in a mental health unit.
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