What is the most important factor for the nurse to assess when doing an admission assessment of a client with a history of alcoholism?
If the client has a history of addictive behaviors
Whether the client has had previous rehabilitation for alcoholism
Their previous and current coping skills
When the client last had a drink of alcohol
The Correct Answer is D
d. When the client last had a drink of alcohol
Explanation of Choices
Choice A Reason: If the Client Has a History of Addictive Behaviors
Assessing whether the client has a history of addictive behaviors is important as it provides insight into the client’s overall pattern of substance use and potential risk for relapse. However, while this information is valuable for developing a comprehensive treatment plan, it is not the most immediate concern during the initial admission assessment. The primary focus should be on identifying any immediate risks or needs, such as the potential for alcohol withdrawal.
Choice B Reason: Whether the Client Has Had Previous Rehabilitation for Alcoholism
Knowing whether the client has had previous rehabilitation for alcoholism can help the nurse understand the client’s treatment history and any previous interventions that may have been effective or ineffective. This information is useful for planning ongoing care and support. However, it is not the most critical factor to assess during the initial admission, as it does not directly address the client’s current physical and mental state.
Choice C Reason: Their Previous and Current Coping Skills
Evaluating the client’s previous and current coping skills is essential for understanding how they manage stress and triggers related to their alcoholism. This assessment can inform the development of personalized coping strategies and support mechanisms. Nonetheless, while important for long-term treatment planning, it is not the most urgent factor to assess during the initial admission.
Choice D Reason: When the Client Last Had a Drink of Alcohol
Determining when the client last had a drink of alcohol is the most important factor to assess during the initial admission. This information is crucial for predicting the onset of alcohol withdrawal symptoms, which can begin as early as 4 to 6 hours after the last drink. Early identification of potential withdrawal allows the healthcare team to implement appropriate monitoring and interventions to manage withdrawal symptoms and prevent complications. Alcohol withdrawal can be life-threatening if not properly managed, making this assessment a top priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Is not responding to other clients on the unit.
While a lack of response to other clients can indicate social withdrawal and isolation, which are common in depressive episodes, it does not necessarily indicate an immediate risk to the client’s safety. This behavior is concerning but does not require the highest priority intervention compared to other behaviors that may indicate a risk of self-harm or suicidal ideation.
Choice B Reason: Is refusing to take their prescribed mood stabilizer.
Refusing medication is a significant concern as it can lead to worsening of symptoms and destabilization of the client’s condition. However, this behavior does not indicate an immediate risk to the client’s safety. The nurse should address this issue promptly, but it is not the highest priority compared to behaviors that suggest suicidal ideation.
Choice C Reason: Angrily argues with another client stating, “God is dead.”
This behavior indicates agitation and potential conflict with others, which can be problematic in a clinical setting. However, it does not directly suggest an immediate risk to the client’s safety. The nurse should intervene to de-escalate the situation and provide support, but this is not the highest priority compared to signs of suicidal ideation.
Choice D Reason: States, “There is no future when you feel so depressed.”
This statement is highly concerning as it indicates feelings of hopelessness and potential suicidal ideation. Expressions of hopelessness and statements about the future being bleak are significant risk factors for suicide. The nurse should prioritize this behavior for immediate intervention to assess the client’s risk of self-harm and provide appropriate support and safety measures.
Correct Answer is ["6.7"]
Explanation
Step 1: Convert the total daily dose from grams to milligrams. 1.2 grams × 1000 = 1200 milligrams Result: 1200 milligrams
Step 2: Divide the total daily dose by the number of doses per day to find the dose per administration. 1200 milligrams ÷ 3 = 400 milligrams per dose Result: 400 milligrams per dose
Step 3: Determine how many milliliters are needed for each dose. The medication is supplied as 300 mg/5 mL. 400 milligrams ÷ 300 milligrams = (400 ÷ 300) = 1.3333 Result: 1.3333
Step 4: Multiply the result by the volume (5 mL) to find the volume needed per dose. 1.3333 × 5 mL = 6.6665 mL Result: 6.6665 mL
Step 5: Round the result to the nearest tenth. 6.6665 mL rounded to the nearest tenth = 6.7 mL Result: 6.7 mL
The nurse will administer 6.7 mL per dose.
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