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 C
Explanation
A. "If I were you, I would go to a few therapy sessions to give them a try": This statement is not appropriate because it places the nurse's personal perspective onto the client, potentially pressuring them. It does not respect the client's autonomy in making their own decisions.
B. "One of my friends went to group therapy and they improved significantly": Sharing personal experiences can make the client feel uncomfortable and may not be relevant to their own situation. It can also create a sense of comparison, which is not helpful.
C. "You have the right to refuse to attend group therapy": This statement is respectful of the client's autonomy and acknowledges their right to make decisions about their care. It empowers the client and maintains their dignity while respecting their refusal.
D. "You should go to group therapy if you want to get better": This statement may feel coercive, as it implies that the client "should" attend therapy to improve. It might lead the client to feel guilty or pressured rather than supported in their choice.
Correct Answer is D
Explanation
A. Has a history of gastric reflux: Gastric reflux is not a contraindication for selegiline transdermal. This medication is primarily concerned with interactions that may affect the central nervous system or blood pressure, rather than gastric issues.
B. Has a history of cholelithiasis: A history of gallstones (cholelithiasis) is not a contraindication for selegiline transdermal. This medication does not have a known direct effect on the gallbladder or bile ducts.
C. Drinks a glass of orange juice daily: There is no significant interaction between selegiline and orange juice. Clients should, however, avoid tyramine-rich foods to prevent hypertensive crises, but orange juice is not a concern in this case.
D. Takes St. John's Wort daily: This is a contraindication. Selegiline is a monoamine oxidase inhibitor (MAOI), and taking it in combination with St. John's Wort can increase the risk of serotonin syndrome, a potentially life-threatening condition. This interaction should be avoided.