Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?
Maintain a quiet, non-stimulating environment.
Force oral fluids and provide frequent small meals.
Confront the client's denial of substance abuse.
Encourage attendance and group participation.
The Correct Answer is A
Choice B reason: Forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. Although hydration and nutrition are important to prevent dehydration and electrolyte imbalance, they are not the priority in this case. The client may have difficulty swallowing, vomiting, or aspiration due to altered mental status.
Choice C reason: Confronting the client's denial of substance abuse is not an appropriate intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or respond rationally to such confrontation due to impaired cognition and perception. The nurse should avoid arguing or challenging the client's beliefs and focus on providing safety and comfort.
Choice D reason: Encouraging attendance and group participation is not a feasible intervention for a client with alcohol withdrawal delirium. The client may not be able to participate in any social or educational activities due to severe withdrawal symptoms and delusions. The nurse should limit visitors and stimuli and provide one-to-one supervision and reassurance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Administering a half dose now is not advisable, because it may result in underdosing or overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a partial dose may not achieve therapeutic levels or may exceed safe levels.
Choice B: Giving another dose is not advisable, because it may result in overdosing of digoxin. Digoxin has a narrow therapeutic range and a high risk of toxicity, especially in infants and children. The amount of digoxin absorbed by the infant before vomiting is unknown, so giving a full dose may exceed safe levels and cause adverse effects such as nausea, vomiting, bradycardia, arrhythmias, or visual disturbances.
Choice C: Mixing the next dose with food is not advisable, because it may affect the absorption and bioavailability of digoxin. Digoxin should be taken on an empty stomach or at least one hour before or two hours after meals, because food can interfere with its absorption from the gastrointestinal tract and reduce its effectiveness.
Choice D:Withholding the dose is the safest option. If vomiting occurs within 30 minutes of administration, it’s generally advised to skip that dose to avoid the risk of overdose.The next dose should be given as scheduled Digoxin has a long half-life and accumulates in tissues, so missing one dose will not significantly affect its therapeutic effect. Withholding this dose will avoid overdosing and toxicity of digoxin, which can be life-threatening in infants and children. The nurse should also advise the mother to resume the regular dosing schedule and monitor the infant's pulse rate and signs of digoxin toxicity.
Correct Answer is C
Explanation
Choice A: Reinforcing need for adequate hydration is not the most important action for the nurse to implement, as this is a general recommendation for all clients and does not address the specific needs of this client. This is a distractor choice.
Choice B: Providing typed instructions for healthy diet selection is not the most important action for the nurse to implement, as this may not be feasible or accessible for this client who lives in a poor neighborhood and may have limited resources and literacy. This is another distractor choice.
Choice C: Scheduling follow-up appointments with specialists is the most important action for the nurse to implement, as this can ensure that this client receives continuous and comprehensive care for their complex and chronic conditions, which can improve their outcomes and quality of life. Therefore, this is the correct choice.
Choice D: Demonstrating specific breathing and walking exercises is not the most important action for the nurse to implement, as this can be done by other health care professionals or at home by the client. This is another distractor choice.
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