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 C

Explanation

A. A family history of dementia may be relevant but is not typically associated with violent nightmares. Alcohol use is more directly related to this symptom.
B. Witness to an accident may be a traumatic experience, but it does not specifically address the symptom of violent nightmares.
C. Alcohol use can contribute to sleep disturbances, including nightmares. Exploring the client's alcohol use is essential in understanding the cause of the nightmares.
D. Inadequate diversional activity is a broad concept and may not be directly related to the specific symptom of violent nightmares.

A. Take the medication each morning beginning 48 hours after your last drink of alcohol. B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication. C. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily. D. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol.

Correct Answer is A

Explanation

A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.

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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

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

Correct Answer is C

Explanation

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

Correct Answer is A

Explanation

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