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 B

Explanation

A. Oxygen saturation is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
B. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Therefore, assessing the client's blood pressure is essential to monitor for potential hypertensive effects.
C. Bowel sounds are not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
D. Pupil response is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.

A. Explain implied consent to the client's family. B. Ask the charge nurse to obtain informed consent. C. Contact the facility social worker to obtain the consent. D. Request that the client's guardian sign the consent.

Correct Answer is D

Explanation

A. Explaining implied consent to the client's family does not address the need for obtaining informed consent for a legally incompetent client.
B. Asking the charge nurse to obtain informed consent may not be appropriate, as the responsibility for obtaining consent typically falls on the healthcare provider or a designated individual.
C. While the social worker may be involved in the process of obtaining consent for a legally incompetent client, it is not their sole responsibility, and the nurse should be actively involved in the process.
D. When a client has been declared legally incompetent, consent must be obtained from the client's legally appointed guardian or surrogate decision-maker.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

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

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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