A client with a history of substance use disorder is admitted for detoxification. Which component is essential for identifying outcomes in the client's care plan?

Collaborate with the healthcare team to set realistic goals

Implement interventions immediately to stabilize the client

Focus solely on the client's physical health needs

Document the client's current condition and medical history

Answer and Explanation

The Correct Answer is A

Choice A reason: Collaboration with the healthcare team sets realistic, measurable outcomes for detoxification, aligning with the client’s needs. Scientifically, goal-setting engages prefrontal cortex planning, enhancing motivation and adherence. This ensures holistic care, addressing psychological and physical aspects of substance use disorder, reducing relapse risk by targeting neurobiological reward pathways.

Choice B reason: Immediate interventions stabilize acute symptoms but don’t define outcomes. Detoxification requires clear goals to measure progress. Scientifically, without outcome-focused planning, interventions may miss psychological triggers, like dopamine-driven cravings, limiting long-term recovery. Stabilization is critical but secondary to establishing measurable goals for sustained sobriety.

Choice C reason: Focusing solely on physical health neglects psychological aspects of substance use disorder. Addiction involves complex neural reward pathways, including dopamine dysregulation. Scientifically, ignoring mental health risks relapse, as unaddressed emotional triggers can drive substance use, undermining detoxification outcomes and long-term recovery efforts.

Choice D reason: Documentation is essential for tracking but doesn’t define outcomes. It records physical and psychological status, aiding care continuity. Scientifically, while it supports monitoring, it doesn’t set goals to address addiction’s neurobiological basis, like reward-seeking behavior, making it less critical than collaborative goal-setting for effective detoxification planning.

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Correct Answer is B

Explanation

Choice A reason: Administering anti-anxiety medication immediately risks inappropriate treatment without assessment. Acute anxiety post-trauma involves heightened amygdala activity and cortisol. Scientifically, premature medication may disrupt neurotransmitter balance, potentially worsening confusion or delaying stabilization of trauma-induced stress responses, hindering recovery.

Choice B reason: A quiet space and reassurance reduce anxiety by calming amygdala-driven stress responses. Scientifically, this lowers cortisol, stabilizing autonomic arousal and promoting emotional regulation. This creates safety, mitigating trauma’s neurobiological impact and supporting recovery by addressing acute anxiety and confusion effectively post-accident.

Choice C reason: Leaving the patient alone risks worsening anxiety and confusion. Trauma-induced stress elevates cortisol and amygdala activity. Scientifically, isolation may exacerbate dissociation or fear, delaying emotional stabilization. Supportive intervention is needed to address neurobiological stress responses and ensure psychological safety post-traumatic event.

Choice D reason: Asking for detailed recounting risks re-traumatization, intensifying anxiety. Scientifically, premature trauma processing heightens amygdala activity and cortisol, worsening confusion and stress responses. Stabilization through a calm environment is needed first to ensure emotional readiness for processing trauma’s psychological impact safely.

A. Prescribe medication to manage anxiety symptoms B. Encourage avoidance of all situations that remind them of the trauma C. Develop a safety plan and provide information on support groups D. Encourage the patient to talk about their experiences to everyone

Correct Answer is C

Explanation

Choice A reason: Prescribing medication isn’t a nursing role and requires assessment. PTSD from intimate partner violence involves amygdala-driven hyperarousal. Scientifically, premature medication risks inappropriate treatment, potentially disrupting neurotransmitter balance without addressing safety or psychological needs, delaying effective stabilization of trauma-related symptoms.

Choice B reason: Avoiding all trauma reminders is impractical and may reinforce fear. Scientifically, blanket avoidance heightens amygdala activity, perpetuating PTSD symptoms like hypervigilance. Structured trigger management is needed, as total avoidance delays trauma processing, risking chronic stress responses and hindering psychological recovery.

Choice C reason: A safety plan and support group information ensure protection and emotional support. Scientifically, safety reduces cortisol and amygdala hyperactivity, stabilizing PTSD symptoms. Support groups foster resilience, addressing trauma’s psychological impact, making this the priority to mitigate ongoing harm and promote recovery.

Choice D reason: Encouraging indiscriminate trauma discussion risks re-traumatization and breaches privacy. Scientifically, uncontrolled disclosure can heighten amygdala-driven stress responses, worsening PTSD. Structured therapy is needed to process trauma safely, as open sharing may exacerbate anxiety or shame, delaying psychological stabilization.

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A client with a history of substance use disorder is admitted for detoxification. Which component is essential for identifying outcomes in the client's care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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