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 A
Explanation
a. The CAGE Questionnaire
Explanation of Choices
Choice A Reason: The CAGE Questionnaire
The CAGE Questionnaire is a widely used screening tool for identifying potential alcohol use disorders. It consists of four questions that focus on key aspects of alcohol dependency: Cutting down, Annoyance by criticism, Guilty feelings, and Eye-openers (drinking first thing in the morning). This tool is quick to administer and has been validated in various clinical settings, making it an effective choice for initial screening of alcohol problems. The CAGE Questionnaire is particularly useful in preoperative assessments to identify patients who may be at risk for alcohol-related complications during and after surgery.
Choice B Reason: The Abnormal Involuntary Movement Scale
The Abnormal Involuntary Movement Scale (AIMS) is used to assess the severity of tardive dyskinesia and other involuntary movements, typically in patients taking antipsychotic medications. It is not designed to screen for alcohol use disorders. Therefore, it would not be appropriate for evaluating a client suspected of having a drinking problem.
Choice C Reason: The Clinical Institute Withdrawal Assessment Scale
The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is a tool used to assess the severity of alcohol withdrawal symptoms. While it is valuable for managing patients already known to have alcohol dependence, it is not a primary screening tool for identifying alcohol use disorders. The CIWA-Ar is more appropriate for monitoring patients during detoxification rather than initial screening.
Choice D Reason: Refer the Client for Physician Evaluation
Referring the client for a physician evaluation is a reasonable step if the nurse suspects a drinking problem. However, using a validated screening tool like the CAGE Questionnaire can provide immediate, actionable information that can guide the next steps in care. The CAGE Questionnaire can help determine the severity of the problem and whether a referral to a specialist is necessary.
Correct Answer is C
Explanation
The correct answer is c. Pepperoni pizza and red wine.
Choice A Reason:
Apple pie and coffee are generally safe to consume while taking MAOIs. These foods do not contain high levels of tyramine, which is the substance that can cause dangerous interactions with MAOIs. Tyramine is found in aged, fermented, or cured foods, and neither apple pie nor coffee falls into these categories.
Choice B Reason:
A bagel with cream cheese and tea is also considered safe for individuals taking MAOIs. Cream cheese is a fresh cheese and does not contain high levels of tyramine. Tea, while containing caffeine, does not pose a significant risk of tyramine interaction.
Choice C Reason:
Pepperoni pizza and red wine are high in tyramine and should be avoided by individuals taking MAOIs. Pepperoni is a cured meat, and red wine is a fermented beverage, both of which can lead to a hypertensive crisis when consumed with MAOIs. This combination can cause a dangerous spike in blood pressure, making it the correct answer to the question.
Choice D Reason:
Potato chips and diet cola do not contain high levels of tyramine and are generally safe to consume while taking MAOIs. Potato chips are not aged or fermented, and diet cola, although containing caffeine, does not pose a significant risk of tyramine interaction.
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