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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:

Asking the client "Why do you think you might have cancer when your diagnosis is a benign condition?" could be perceived as dismissive of the client's feelings. It's important for the nurse to acknowledge the client's concerns rather than questioning their rationale.

Choice B reason:

While it is true that discussing specific medical concerns with a provider is important, the statement "I think that's something you need to discuss with your provider" does not address the client's immediate emotional needs. The nurse should provide support and acknowledge the client's feelings before suggesting a discussion with the provider.

Choice C reason:

The response "I'm hearing that you are concerned that it might turn out that you have cancer" is an example of reflective listening. It shows that the nurse is actively listening and validating the client's concerns. This approach can help the client feel understood and supported during a stressful time.

Choice D reason:

Saying "I'm looking at your chart here and I don't see any reason for you to worry about that" may seem reassuring, but it does not validate the client's feelings. The nurse should acknowledge the client's fears and provide comfort, rather than simply referring to the medical facts.

A. "How long has this been going on?" B. "It sounds like you're having a difficult time." C. "Why do you think you are so anxious?" D. "Have you talked to your parents about this yet?"

Correct Answer is B

Explanation

Choice A Reason:

Asking "How long has this been going on?" is a relevant question that can help the nurse understand the duration of the client's anxiety and concentration issues. However, it may not immediately provide the empathetic connection that can encourage the client to open up more about their feelings.

Choice B Reason:

"It sounds like you're having a difficult time" is an empathetic statement that acknowledges the client's distress and can help establish rapport. This response validates the client's feelings and invites them to share more about their experience, which is essential in forming a therapeutic nurse-client relationship.

Choice C Reason:

"Why do you think you are so anxious?" could prompt the client to reflect on possible causes of their anxiety, but it might also be perceived as confrontational or accusatory. It's important for the nurse to create a nonjudgmental atmosphere that encourages open communication.

Choice D Reason:

"Have you talked to your parents about this yet?" assumes that the client's parents are part of their support system and that the client is willing or able to discuss their anxiety with them. This question might not be appropriate for all clients, especially if family relationships are a source of stress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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