A nurse in a substance abuse clinic is assessing a client who is prescribed disulfiram (Antabuse). The client states he stopped the medication after developing severe nausea and vomiting. Which of the following does the nurse realize is most likely the cause of the client's symptoms?
The client took an overdose of the medication.
The client demonstrated an allergic response to the medication.
The client experienced a common side effect of the medication.
The client consumed alcohol while taking the medication.
The Correct Answer is D
Choice A Reason:
An overdose of disulfiram can cause symptoms such as nausea and vomiting, but it is less likely to be the cause in this scenario. Overdoses typically present with more severe symptoms, including seizures and coma in rare cases¹. The client's symptoms are more consistent with a disulfiram-alcohol reaction.
Choice B Reason:
An allergic response to disulfiram can cause symptoms such as rash, itching, and swelling, but severe nausea and vomiting are not typical allergic reactions². Allergic reactions would also likely present with other symptoms such as difficulty breathing or hives, which are not mentioned in this case.
Choice C Reason:
While nausea and vomiting can be common side effects of disulfiram, the severity described by the client suggests a more significant reaction. Common side effects are usually milder and do not typically cause the client to stop the medication abruptly.
Choice D Reason:
The most likely cause of the client's severe nausea and vomiting is the consumption of alcohol while taking disulfiram. Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, leading to an accumulation of acetaldehyde when alcohol is consumed. This results in unpleasant effects such as severe nausea, vomiting, headache, and flushing. The client's symptoms align with this reaction, making it the most probable cause.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason:
Rewarding the client for their change in behavior may seem positive, but it is not an appropriate nursing action in this context. It could reinforce the idea that only certain behaviors receive attention, which is not conducive to the therapeutic process.
Choice B reason:
Asking the client why their behavior has changed is not the most appropriate initial action. While understanding the client's perspective is important, it is more crucial to assess the situation for safety concerns, as sudden mood changes can sometimes precede impulsive actions.
Choice C reason:
Encouraging the family to take the client out of the facility for short periods of time is not advisable without a proper assessment of the client's stability and readiness for such activities. It is essential to ensure that the client is safe and that their treatment plan is being followed.
Choice D reason:
Monitoring the client's whereabouts at all times is the most appropriate action. A sudden change in mood can be a warning sign of increased risk for impulsive behavior, including self-harm or suicide. Continuous monitoring ensures the client's safety and allows for immediate intervention if necessary.
Correct Answer is C
Explanation
Choice A reason:
Documenting the client's verbatim statements is crucial for legal purposes and for ensuring that the client's experience is accurately recorded. However, this is not the first action to take. The nurse must first address any immediate medical concerns, which include identifying and treating injuries.
Choice B reason:
Asking for permission to take photographs is an important part of collecting evidence, but it should be done after addressing immediate health concerns and with the client's consent. It is also essential that this step is performed in a sensitive and non-judgmental manner.
Choice C reason:
Determining any physical signs of injury is the most critical initial step. The nurse must assess for injuries that may require immediate intervention. This aligns with the priorities of care in emergency nursing, which focus on stabilizing the patient's condition and addressing urgent health issues.
Choice D reason:
Providing community sexual assault support contacts is an important aspect of holistic care and ensures that the client has access to ongoing support. However, this action follows after immediate health concerns have been addressed and should be part of the long-term care plan.
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