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
Explanation
A. Encouraging physical activity during the day has been shown to improve mood and reduce symptoms of depression by increasing endorphin levels and promoting a sense of well-being.
B. Identifying and scheduling alternative group activities for the client may be helpful in reducing social isolation and improving mood but should not replace physical activity.
C. Discouraging the client from expressing feelings of anger is not appropriate, as it may suppress emotions and hinder therapeutic communication. Instead, the nurse should encourage the client to express and explore their emotions in a healthy manner.
D. Keeping a bright light on in the client's room at night may disrupt sleep patterns and exacerbate symptoms of depression, as individuals with depression often have disturbances in their sleep-wake cycle.
Correct Answer is D
Explanation
A. This statement reflects a realistic acknowledgment of the grieving process and does not necessarily indicate clinical depression.
B. Expressing dependence on family support is a common coping mechanism during grief and does not necessarily indicate clinical depression.
C. Feelings of anger are common during the grieving process and do not necessarily indicate clinical depression.
D. Feeling numb or anhedonic, the inability to experience pleasure, is a symptom commonly associated with clinical depression and should be reported to the provider for further evaluation and intervention.
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