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 ["30"]
Explanation
First, we need to find the concentration of insulin in the IV solution, which is the ratio of insulin units to saline volume. To do this, we use the given information that the IV solution contains 100 units in 250 ml. So, we divide 100 by 250 and get 0.4 units/ml.
Next, we need to calculate the infusion rate in ml/hour for the ordered dose of 12 units/hour. To do this, we use the ratio of insulin units to saline volume, which is 0.4 units/ml. So, we set up a proportion as follows:
0.4/1=12/x
To solve for x, we cross-multiply and get 0.4 x = 12. Then, we divide both sides by 0.4 and get x = 30. So, the infusion rate is 30 ml/hour.
Therefore, the nurse should program the infusion pump to deliver 30 ml/hour..
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a critical finding for the nurse to report, as this is a common sign of pneumonia and does not indicate an adverse reaction to meropenem. This is a distractor choice.
Choice B: Nausea and headache are not urgent findings for the nurse to report, as these are mild side effects of meropenem and can be managed with supportive measures. This is another distractor choice.
Choice C: Watery diarrhea is an important finding for the nurse to report, as this can indicate a serious complication of meropenem, such as Clostridioides difficile infection, which can cause severe dehydration, electrolyte imbalance, and sepsis. Therefore, this is the correct choice.
Choice D: Increased fatigue is not a significant finding for the nurse to report, as this can be related to the client's underlying condition and does not suggest a problem with meropenem. This is another distractor choice.
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