A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Check the client's pupil reactivity.

Perform a developmental screening test.

Prepare the client for a CT scan.

Obtain a urine specimen.

Monitor the client’s vital signs frequently.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Ongoing communication with team members is crucial in managing care for clients with personality disorders, as it ensures consistency and support among caregivers.

Choice B reason: While solving clients' problems is a goal, it is not a technique to manage the nurse's frustration.

Choice C reason: Recognizing that behavior changes can occur quickly allows the nurse to adjust care plans promptly and may reduce frustration.

Choice D reason: It is not advisable to consider clients as personal friends, as this can blur professional boundaries and potentially lead to frustration.

Choice E reason: Discussing feelings of anger or frustration with colleagues can provide a support system for the nurse, helping to manage stress and prevent burnout.

A. "I will start basing my decisions and actions on reality." B. "I am going to have to learn to trust other people." C. "I will be able to differentiate when my suspicions are true." D. "I understand the origins of my paranoid thinking."

Correct Answer is B

Explanation

Choice A reason: This statement shows that the client is willing to ground their decisions in reality, which is a key step in managing paranoid personality disorder.

Choice B reason: Trusting others is important, but it does not indicate that the client has learned to validate their ideas before acting.

Choice C reason: Differentiating true suspicions is part of managing the disorder, but it does not demonstrate an understanding of the need to validate ideas with others.

Choice D reason: Understanding the origins of paranoid thinking is insightful, but it does not show that the client has learned to validate their ideas before taking action.

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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action. Which statement made by the client indicates that the teaching is effective?

Correct Answer is B

Explanation

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