A nurse in a mental health facility is admitting a client.
div id="exhibits">ExhibitsComplete the following sentence by using the lists of options.
The client is at risk of developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices:
- Alcohol withdrawal syndrome: The client’s BAC of 310 mg/dL indicates severe intoxication. As the alcohol clears from the system, withdrawal symptoms such as anxiety, tremors, and seizures may occur, requiring close monitoring to prevent complications like delirium tremens.
- Blood alcohol level of 310 mg/dL: This elevated BAC indicates significant alcohol consumption. As the alcohol is metabolized, the client is at high risk for alcohol withdrawal syndrome and requires close observation to manage withdrawal symptoms as the BAC decreases.
Rationale for incorrect choices:
- Malnutrition: While weight loss and minimal appetite may be concerning, they do not definitively indicate malnutrition. These symptoms are more likely tied to the client’s psychological distress and alcohol use rather than severe nutritional deficiency.
- Alcohol intoxication: The client’s current state is intoxicated; the primary concern at this stage is managing alcohol withdrawal syndrome. Once the alcohol is metabolized, the focus will shift to preventing withdrawal complications which the client is at risk of.
- Respiratory rate of 10/min: A respiratory rate of 10/min is on the low side but not dangerously low. This rate may be associated with alcohol intoxication and will require monitoring but is not immediately alarming unless the client shows signs of respiratory distress.
- Weight loss over the past 3 months and minimal appetite: The weight loss and reduced appetite are concerning but not immediately indicative of malnutrition. These symptoms are likely due to the client’s alcohol use and emotional distress, and further assessment is needed to evaluate nutritional health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decrease in blood pressure: A decrease in blood pressure is a positive sign that the treatment for serotonin syndrome is effective. Treatment typically includes discontinuing the causative medication and providing supportive care to normalize vital signs, including blood pressure.
B. Muscle rigidity: Muscle rigidity is a hallmark sign of serotonin syndrome and indicates that the condition is still present or not yet effectively treated. Successful treatment should reduce muscle rigidity over time.
C. Hyperreflexia: Hyperreflexia (overactive reflexes) is also a common symptom of serotonin syndrome. If the treatment is effective, hyperreflexia should resolve as serotonin levels normalize in the body.
D. Altered mental status: Altered mental status is another indicator of serotonin syndrome. Improvement in serotonin syndrome would be evidenced by a return to normal cognitive function, so persistence of altered mental status suggests that treatment has not yet been fully effective.
Correct Answer is B
Explanation
A. Staying with the client for 15 minutes following meals is insufficient. The nurse should closely supervise the client for a longer duration, typically 45 to 60 minutes after every meal, to prevent them from hiding food, vomiting, or engaging in excessive physical activity to purge calories.
B. Weighing the client every day during the first week of acute care is a critical and standard intervention. Frequent weight checks are vital for monitoring initial physical stability and assessing fluid status to ensure the client is not developing refeeding syndrome, a dangerous metabolic complication that can occur during early nutritional rehabilitation.
C. Schedule the client for a daily exercise program: Exercise may be restricted or minimized in clients with anorexia nervosa, especially in the acute phase of treatment, as excessive exercise can worsen the condition and interfere with recovery.
D. Discuss food-related topics with the client during meals: Discussing food-related topics during meals may increase anxiety or pressure related to food. The focus during meals should be on providing a supportive, non-judgmental environment that encourages normal eating patterns.