A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

Administer methadone hydrochloride.

Monitor for orthostatic hypotension.

Acidify the client's urine.

Implement seizure precautions.

Answer and Explanation

The Correct Answer is D

A.   Methadone hydrochloride is not indicated for the management of alcohol intoxication or withdrawal. It is primarily used for opioid addiction treatment.
B.   While monitoring for orthostatic hypotension is important in clients with alcohol use disorder, implementing seizure precautions is a higher priority because alcohol withdrawal can lead to
seizures.
C.   Acidifying the client's urine is not indicated in the care of an intoxicated client with alcohol use disorder.
D.   Implementing seizure precautions is essential in clients with alcohol use disorder who are at risk for alcohol withdrawal syndrome, which can include seizures as a potential complication.

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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.

A. Give the client atropine 30 min before the procedure. B. Witness the client's signature on the consent for the procedure. C. Check the client's condition after the procedure. D. Assist the client to ambulate for the first time following the procedure.

Correct Answer is D

Explanation

A. Administering medications, such as atropine, requires nursing judgment and assessment of the client's condition, which should not be delegated to assistive personnel.
B. Witnessing the client's signature on the consent form ensures that the client provides informed consent for the procedure and requires nursing judgment.
C. Assessing the client's condition after the procedure involves monitoring vital signs, level of consciousness, and potential adverse reactions, which require nursing assessment and judgment.
D. Assisting the client to ambulate after the procedure is a task that can be safely delegated to assistive personnel, as long as the client's condition is stable and there are no contraindications to ambulation.

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A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?

Nursing Test Bank

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