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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 B

Explanation

A. Taking medication with a meal may help alleviate gastrointestinal side effects but is unlikely to affect dizziness caused by medication.
B. Quetiapine, an antipsychotic medication, commonly causes orthostatic hypotension, which can lead to dizziness. Explaining this to the client helps provide education about the medication's side effects.
C. Dizziness is not typically indicative of an allergic reaction to quetiapine. Advising the client to stop the medication immediately based solely on dizziness is not appropriate.
D. Taking the medication in the morning may or may not affect dizziness, as it depends on the individual's response to the medication. Additionally, orthostatic hypotension can occur at any time of day, not just in the morning.

A. Offer to talk with the caregiver about their feelings. B. Refer the caregiver to a local support group. C. Discuss relaxation techniques with the caregiver. D. Consult social services to explore counseling for the caregiver.

Correct Answer is A

Explanation

A. Offering to talk with the caregiver about their feelings provides immediate support and validation of their emotions. It allows the caregiver to express their concerns and stressors, which can help alleviate some of the caregiver's distress.
B. Referring the caregiver to a local support group is a helpful intervention but may not address the caregiver's immediate emotional needs. Offering immediate support by listening and empathizing is the first step.

C. Discussing relaxation techniques with the caregiver may be beneficial, but addressing the caregiver's emotional distress should take precedence.
D. Consulting social services to explore counseling for the caregiver is a valuable intervention, but offering immediate support by engaging in a conversation about their feelings is the most appropriate initial action.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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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.