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 B
Explanation
Choice B is correct because initiating a continuous infusion of IV fluids per prescription has highest priority for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. Pyloric stenosis causes projectile vomiting and dehydration, which can lead to metabolic alkalosis and electrolyte imbalance. The infant needs IV fluids to correct these abnormalities and prevent complications.
Choice A is incorrect because marking an outline of the “olive-shaped” mass in the right epigastric area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The “olive-shaped” mass is a palpable sign of pyloric stenosis, but it does not require any intervention before surgery.
Choice C is incorrect because monitoring amount of intake and infant's response to feedings is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The infant may have difficulty feeding due to vomiting and gastric distension, which can worsen their dehydration and malnutrition. The infant may need to be kept NPO (nothing by mouth) before surgery.
Choice D is incorrect because instructing parents regarding care of the incisional area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The incisional area will need proper care after surgery, but this can be taught later when the infant is stable and ready for discharge.
Correct Answer is B
Explanation
Choice A: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
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