A nurse in a mental health facility is admitting a client.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
A. Participation in group therapy - This indicates the client's engagement in therapeutic interventions, suggesting progress in addressing their alcohol use disorder and coping with grief.
B. Movement through the stages of grief - Progress in processing grief is a positive sign of emotional healing and adjustment.
C. Client resolves to limit alcohol consumption - While resolution to limit alcohol consumption would be an ideal outcome, there is no specific indication in the scenario that the client has made this resolution.
D. Appetite - Although improvement in appetite would be a positive sign, there is no specific mention of the client's appetite in the provided information, so it cannot be assumed that this finding indicates progress in the client's plan of care.
E. Cognition - Improvement in cognition suggests a reduction in the effects of alcohol intoxication or withdrawal, indicating progress in treatment.
F. Vital signs - Stable vital signs within normal range suggest physiological stability and potentially a positive response to treatment.
Correct Answer is ["10"]
Explanation
First, we need to determine how many milligrams (mg) are in each milliliter (mL) of the solution.
The available methylphenidate oral solution has a concentration of 10 mg per 5 mL.
To find out how many milligrams are in 1 mL of the solution, we divide 10 mg by 5 mL: 10 mg / 5 mL = 2 mg/mL
The child's prescription is for 40 mg per day, divided into two doses. So, each dose should contain:
40 mg / 2 doses = 20 mg per dose 2mg=1ml
20mg= 20*1/2= 10ml
Therefore, the nurse should administer 10 mL of methylphenidate oral solution per dose
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