A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

Administer disulfiram immediately.

Place in a side-lying position with the head of the bed elevated.

Give lorazepam PRN for signs of withdrawal.

Provide thiamine and folate supplements as prescribed.

Answer and Explanation

The Correct Answer is B

A.   Administering disulfiram is not the priority in the immediate care of a client with a closed head injury and elevated blood alcohol level. The focus should be on ensuring the client's safety and preventing complications related to the head injury.
B.   Placing the client in a side-lying position with the head of the bed elevated is crucial to prevent aspiration and maintain airway patency in a client who is difficult to arouse due to alcohol intoxication.
C. Giving lorazepam for signs of withdrawal may be necessary but does not address the immediate risk of aspiration in a client with altered consciousness.
D.   Providing thiamine and folate supplements is important for clients with alcohol use disorders, but the priority in this scenario is airway protection and preventing complications related to the head injury.

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Correct Answer is D

Explanation

A. Creatinine primarily reflects kidney function, not the metabolism of lithium in the liver.
B. Amitriptyline's effects on lithium toxicity are not directly related to creatinine levels.
However, both drugs can impact kidney function.
C. The decision to change medication based on creatinine levels involves assessing the impact on kidney function, not the combination of lithium and amitriptyline per se.
D. Lithium is excreted by the kidneys, and monitoring creatinine levels helps assess renal function, guiding the appropriate dosage and preventing lithium toxicity.

A. Support the client to list small behavioral changes needed. B. Explain the specific skills needed to prevent a relapse. C. Provide teaching on the symptoms of substance use dependence. D. Advise the client to reschedule until committing to recovery.

Correct Answer is A

Explanation

A. Supporting the client to list small behavioral changes is a person-centered and achievable approach to promote progress.
B. Explaining specific skills needed to prevent a relapse may be overwhelming at this early stage.
C. Providing teaching on symptoms of substance use dependence may not be the most immediate and practical response to the client's expressed desire for positive change.
D. Advising the client to reschedule until committing to recovery is not supportive and may discourage the client's motivation for positive change.

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A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

Correct Answer is A

Explanation

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