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A nurse in a mental health facility is admitting a client.

Exhibits

A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Blood alcohol level

Client's recent loss

Smoking history

Client's recent consumption of alcohol

Cardiac assessment

Neurological assessment

Genitourinary assessment

Respiratory assessment

Gastrointestinal assessment

Answer and Explanation

Correct Answer : A,B,D,F,I

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E.   Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F.   The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G.   Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

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Correct Answer is C

Explanation

A. Changing the subject when the client becomes upset may invalidate their feelings and hinder emotional expression and processing.
B. Discouraging the client from forming new relationships may deprive the client of potentially meaningful connections during their remaining time.
C. Allowing the client unlimited time for the grieving process acknowledges the client's emotional response to their diagnosis and respects their individual needs and coping mechanisms.

D. Offering advice about treatment choices may be appropriate in some situations but should be done in collaboration with the client's healthcare team and in consideration of their wishes and values.

A. Hepatitis B infection B. Hypothyroidism C. Knee arthroplasty 1 month ago. D. Recent head injury

Correct Answer is D

Explanation

A. Hepatitis B infection is not a contraindication for prescribing bupropion for smoking cessation.
B. Hypothyroidism is not a contraindication for prescribing bupropion for smoking cessation.

C. Knee arthroplasty 1 month ago does not contraindicate the use of bupropion for smoking cessation.
D. Bupropion is contraindicated in individuals with a recent head injury due to the increased risk of seizures associated with this medication. Therefore, the nurse should report this finding to the provider.

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A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Nursing Test Bank

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Correct Answer is D

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A nurse in a mental health facility is admitting a client.

Exhibits

A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.