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: Anchovies
Anchovies are a type of small, oily fish that are often used in various dishes for their strong flavor. They are rich in omega-3 fatty acids and other nutrients. However, there is no known interaction between anchovies and disulfiram. Disulfiram specifically interacts with alcohol and alcohol-containing products, causing unpleasant reactions. Therefore, anchovies are not a food item that needs to be avoided while taking disulfiram.
Choice B Reason: Spinach
Spinach is a leafy green vegetable that is high in vitamins, minerals, and antioxidants. It is generally considered a healthy food and does not have any known interactions with disulfiram. Patients taking disulfiram do not need to avoid spinach as it does not contain alcohol or any substances that would cause a reaction with the medication.
Choice C Reason: Grapefruit Juice
Grapefruit juice is known to interact with various medications by affecting the enzymes that metabolize these drugs in the liver. However, there is no specific interaction between grapefruit juice and disulfiram. While grapefruit juice can affect the metabolism of certain medications, it does not cause the same type of reaction that alcohol does when taken with disulfiram. Therefore, it is not necessary for patients on disulfiram to avoid grapefruit juice.
Choice D Reason: Alcoholic Beverages
Alcoholic beverages are the primary substance that must be avoided while taking disulfiram. Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, which is involved in metabolizing alcohol. When alcohol is consumed, acetaldehyde accumulates in the body, leading to unpleasant symptoms such as nausea, vomiting, headache, and flushing. This reaction is intended to deter individuals from drinking alcohol. Therefore, it is crucial for patients taking disulfiram to avoid all forms of alcohol, including alcoholic beverages, to prevent these adverse reactions.
Correct Answer is B
Explanation
The correct answer is b. It’s not my fault.
Choice A Reason: I just don’t remember doing it
This statement might be used by someone trying to avoid responsibility, but it is not as characteristic of antisocial personality disorder (ASPD) as outright denial of fault. Individuals with ASPD often exhibit a lack of accountability and may lie or manipulate to avoid consequences. However, claiming memory loss is less direct than denying responsibility altogether.
Choice B Reason: It’s not my fault
This statement is highly characteristic of antisocial personality disorder. Individuals with ASPD often refuse to take responsibility for their actions and may blame others or external circumstances. This lack of accountability and tendency to deflect blame is a core feature of the disorder, making this the most expected comment.
Choice C Reason: I’m really sorry about all the people I’ve hurt
This statement is unlikely for someone with antisocial personality disorder. People with ASPD typically lack empathy and remorse for their actions. Expressing genuine sorrow and concern for others is not consistent with the typical behavior of someone with this disorder.
Choice D Reason: I’m too ashamed to talk about it
This statement suggests a level of self-awareness and guilt that is not typical of antisocial personality disorder. Individuals with ASPD generally do not experience shame or guilt in the same way as others. They are more likely to be indifferent or dismissive about the consequences of their actions.
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