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 C
Explanation
Choice A: Conversion of the client's PPD test from negative to positive is not the most important information for the nurse to note, as this is an expected finding for a client who has been exposed to tuberculosis and does not affect the administration of isoniazid. This is a distractor choice.
Choice B: History of intravenous drug abuse is not the most important information for the nurse to note, as this is not directly related to the use of isoniazid and does not contraindicate its administration. This is another distractor choice.
Choice C: Current diagnosis of hepatitis B is the most important information for the nurse to note, as this can increase the risk of hepatotoxicity and liver damage from isoniazid, which requires close monitoring and possible dose adjustment. Therefore, this is the correct choice.
Choice D: Length of time of the exposure to tuberculosis is not the most important information for the nurse to note, as this does not influence the dosage or frequency of isoniazid and does not indicate any complication or adverse reaction. This is another distractor choice.
Correct Answer is B
Explanation
Choice A: Ask for a consultation with a psychologist. This is not the best intervention, as it does not address the physical aspect of pain management. A psychologist may help the client cope with emotional distress and cognitive-behavioral strategies to reduce pain perception, but it may not be enough to relieve severe pain.
Choice B: Arrange an appointment with a pain specialist. This is the best intervention, as it addresses the physical aspect of pain management. A pain specialist may prescribe appropriate medications, perform interventional procedures, or recommend alternative therapies to relieve severe pain.
Choice C: Contact a hospice nurse for an evaluation. This is not the best intervention, as it does not address the eligibility criteria for hospice care. Hospice care is intended for clients who have a terminal illness with a life expectancy of six months or less, and who have decided to forego curative treatments. Fibromyalgia is not a terminal illness, and hospice care may not be appropriate for this client.
Choice D: Form an interdisciplinary team for evaluation. This is not the best intervention, as it does not address the urgency of pain management. An interdisciplinary team may consist of various healthcare professionals who can provide holistic care for the client, but it may take time to coordinate and implement their services.
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