A female client is admitted with abdominal pain, possibly due to a gastric ulcer. Two days after admission, the client reports feeling nervous and tremulous. Further assessment reveals that the client's family is bringing a gin and tonic each night to help her relax. Which action(s) should the nurse take? Select all that apply.
Ask the client if she has any alcohol in the room at this time.
Administer an PRN prescription for an antianxiety drug.
Inform the family that they are enabling the client.
Observe for signs to determine if client is inebriated.
Schedule a conference with the client and family members.
Correct Answer : A,D,E
A. Ask the client if she has any alcohol in the room at this time: This is an essential step in assessing for immediate safety and contraband that may impact her treatment plan, especially considering her symptoms and possible withdrawal risk.
B. Administer a PRN prescription for an antianxiety drug: This could mask symptoms of alcohol withdrawal or interact negatively with alcohol. Medication should be given only after thorough assessment and consultation.
C. Inform the family that they are enabling the client: While family education is important, using accusatory language like "enabling" can damage therapeutic relationships. A nonjudgmental, supportive approach is better.
D. Observe for signs to determine if client is inebriated: Monitoring for inebriation supports accurate clinical assessment and decisions about withdrawal protocols, safety, and medication timing.
E. Schedule a conference with the client and family members: A joint meeting allows open discussion, identifies care goals, and promotes understanding and support from all parties involved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.
B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.
C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.
D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.
Correct Answer is C
Explanation
A. Type of anticonvulsant prescribed: While the class or type of anticonvulsant influences seizure control, it does not directly indicate whether the client is receiving a sufficient dosage. The therapeutic effectiveness depends more on blood concentration than classification.
B. History of a recent illness: Acute illness can temporarily lower the seizure threshold, but it is a less specific indicator for predicting recurrence than pharmacologic control. The underlying condition must be assessed, but medication levels are more predictive of seizure risk.
C. Therapeutic level of medication: A subtherapeutic drug level is a strong predictor of seizure recurrence. Maintaining an adequate plasma concentration ensures optimal seizure control and is crucial in clients recovering from status epilepticus, where precise management is essential.
D. Duration of previous seizure activity: The length of the prior seizure can indicate severity but not the likelihood of recurrence. Even brief seizures can recur if anticonvulsant levels are inadequate, so duration is not as clinically useful as drug level monitoring.
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