A male client with a long history of alcohol dependency arrives in the Emergency Department describing the feeling of bugs crawling on his body. His blood pressure is 170/102 mm Hg, pulse rate is 110 beats/minute, and blood alcohol level (BAL) is 0 mg/dL. Which prescription should the nurse administer?

Haloperidol.

Lorazepam.

Diphenyhydramine.

Thiamine.

Answer and Explanation

The Correct Answer is B

A) Haloperidol is an antipsychotic that may be used for agitation or hallucinations, but it is not the first-line treatment for alcohol withdrawal symptoms. Administering haloperidol without addressing withdrawal may not be effective and could lead to further complications.

B) Lorazepam is a benzodiazepine and is the preferred medication for managing alcohol withdrawal symptoms, including agitation, anxiety, and hallucinations. It helps reduce the risk of severe withdrawal symptoms and seizures while providing sedative effects. Given the client’s symptoms of feeling bugs crawling on his body, which may indicate tactile hallucinations due to withdrawal, lorazepam would be the most appropriate choice.

C) Diphenhydramine is an antihistamine that can be used for allergic reactions or as a sedative, but it is not effective for managing alcohol withdrawal symptoms.

D) Thiamine is important to prevent Wernicke's encephalopathy in clients with a history of alcohol dependency, especially if there are signs of confusion or neurological deficits. However, it does not address the immediate symptoms of withdrawal the client is experiencing.

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Correct Answer is C

Explanation

A) Returning at a later time to talk might seem considerate, but it may miss the opportunity to engage with the client in the moment. The client may benefit from having the nurse's presence and support, even if they are slow to respond.

B) Asking a different question could disrupt the process and prevent the client from expressing their feelings. It’s important to allow the client the space to answer the original question rather than shifting topics prematurely.

C) Waiting for the client to respond is the best action. This approach demonstrates patience and respect for the client's current state. By allowing time for a response, the nurse can create a supportive environment, which may help the client feel more comfortable opening up when they are ready.

D) Asking if the client heard the question might feel like an interruption or could add pressure, making the client more anxious. It’s better to give the client space to process and respond without feeling judged or rushed.

A. Explain that these beliefs are related to her illness. B. Explain that distrust is related to feeling anxious. C. Initiate short, frequent contacts with the client. D. Offer to keep the belongings at the nurse's desk.

Correct Answer is C

Explanation

(A) Explain that these beliefs are related to her illness:While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.

(B) Explain that distrust is related to feeling anxious:This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.

(C) Initiate short, frequent contacts with the client:This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.

(D) Offer to keep the belongings at the nurse’s desk:This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

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Correct Answer is C

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Correct Answer is C

Explanation

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