A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

The client will implement alternative strategies for managing anxiety.

The client will acknowledge alcohol dependence and need for treatment.

The client's withdrawal from alcohol will be managed without complications.

The client will rebuild damaged interpersonal relationships.

Answer and Explanation

The Correct Answer is C

A. The client will implement alternative strategies for managing anxiety.

While addressing anxiety is important for the overall well-being of the client, it may not be the highest priority in this context. The immediate physical safety of the client during alcohol withdrawal takes precedence over addressing anxiety.

B. The client will acknowledge alcohol dependence and need for treatment.

Recognizing alcohol dependence and the need for treatment is an important step, but it may not be the highest priority. It is more focused on the client's acceptance and understanding of their situation rather than addressing immediate health risks.

C. The client's withdrawal from alcohol will be managed without complications.

This is the correct answer. Managing alcohol withdrawal without complications is the highest priority goal in this scenario. Alcohol withdrawal can lead to severe physical symptoms, including seizures and delirium tremens, which can be life-threatening. Ensuring the safe and medically supervised management of withdrawal is crucial for the client's immediate well-being.

D. The client will rebuild damaged interpersonal relationships.

While repairing damaged relationships is important for the client's overall rehabilitation, it's not the highest priority in this context. Physical health and safety take precedence over addressing interpersonal issues.

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Correct Answer is A

Explanation

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

A. The client responds to questions with disorganized speech. B. The client reports that voices are telling him to write a novel. C. The client's spouse reports that client has recently gained weight. D. The client is dressed in all black.

Correct Answer is A

Explanation

A. The client responds to questions with disorganized speech:

Disorganized speech is a hallmark of acute mania, often reflecting racing thoughts, pressured speech, and difficulty staying on topic.

B. The client reports that voices are telling him to write a novel:

Reporting that voices are telling the client to write a novel suggests auditory hallucinations, which can occur in various psychiatric conditions, not specifically indicative of acute mania.

C. The client's spouse reports that the client has recently gained weight:

Weight gain is not a typical hallmark of acute mania. In fact, during manic episodes, individuals might experience decreased appetite and sleep, leading to potential weight loss.

D. The client is dressed in all black:

Dressing in all black is not a specific sign of acute mania. While changes in clothing choices or appearance can sometimes be associated with mood changes, this finding alone is not indicative of acute mania.

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A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

Nursing Test Bank

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