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 B
Explanation
A. Encourage the client to reframe their perception of stress: Reframing can be a helpful strategy for less severe anxiety, but during a panic attack, the client may be too overwhelmed to engage in cognitive techniques like reframing. Immediate support is needed first.
B. Guide the client to a location that is quiet and stay with the client: This is the best intervention. A quiet environment helps reduce external stimuli, and staying with the client provides reassurance and safety, helping to calm the overwhelming anxiety during a panic attack.
C. Help the client identify factors that are contributing to the anxiety: While identifying triggers is important for long-term management, during a panic attack, the priority is immediate relief and safety. The client may not be able to engage in reflection during peak anxiety.
D. Ask questions to clarify how the client feels and what they are thinking: During a panic attack, the client is likely to be too overwhelmed to respond meaningfully to questions. The priority is to offer comfort and a calm presence rather than focusing on understanding their thoughts at that moment.
Correct Answer is A
Explanation
A. Helping a client fulfill a need that they are unable to complete independently: Advocacy in healthcare involves supporting and promoting the rights of clients. It includes helping clients meet their needs, especially when they are unable to do so independently due to illness, circumstances, or limitations.
B. Assuring that the health care provider tells the truth and does not mislead: This refers to veracity, which involves truth-telling and honesty in communication with clients, but it does not fully capture the broader role of advocacy.
C. Avoiding intentionally or unintentionally harming clients: This defines nonmaleficence, an ethical principle focused on preventing harm. While important in healthcare, it is not specific to advocacy.
D. Maintaining the premise that all clients are to be treated equally: This refers to justice, an ethical principle that ensures fairness and equality in treatment. It is related to but distinct from advocacy, which is more focused on supporting the client's individual needs.