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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: While encouragement is important, it does not necessarily indicate that the family understands the complexities of anorexia nervosa.

Choice B reason: Eating together can provide support and structure, which are important aspects of recovery in eating disorders.

Choice C reason: While resolving family conflicts is beneficial, it does not directly relate to understanding the eating disorder itself.

Choice D reason: Spending less time discussing troublesome family members does not reflect an understanding of how to support a family member with an eating disorder.

A. Cardiac monitor B. Blood pressure monitor C. Portable x-ray machine D. Electroencephalogram (EEG) monitor E. Ophthalmoscope

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: A cardiac monitor is essential during ECT to monitor the heart's electrical activity, as the procedure can affect heart rate and rhythm.

Choice B reason: A blood pressure monitor is necessary to track the client's blood pressure throughout the procedure, as ECT can cause fluctuations in blood pressure.

Choice C reason: A portable x-ray machine is not typically required in the setup for ECT.

Choice D reason: An EEG monitor is used during ECT to record the electrical activity of the brain, which is crucial for assessing the seizure activity induced by the treatment.

Choice E reason: An ophthalmoscope is not used during ECT; it is an instrument for examining the interior structures of the eye.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse provides education to a client's family about the client's eating disorder, anorexia nervosa. Which statement would indicate that the education was effective?

Correct Answer is B

Explanation

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A client is seeking relief for undiagnosed pain. There is no history of significant physical illness or injury. The history reveals that the client was laid off 4 months ago from a job. Which statement made by the client would most strongly suggest a somatoform disorder?

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client asks the nurse why all of these questions are being asked. Which techniques will the nurse most likely avoid using to foster more therapeutic responses? Select all that apply.

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

The nurse is planning an approach that will be most effective in developing a therapeutic relationship with a client. Which disorder(s) will the nurse best employ a matter-of-fact approach with the client? (Select all that apply.)

The nurse is performing an assessment for a young adolescent and observes a lack of hair on the eyebrows and the hairline. Which statement made by the parent demonstrates an understanding of the type of hair loss the child is experiencing?

The nurse is educating a client with alcoholism who has been in rehabilitation for two weeks to prepare for discharge. Which statement made by the client indicates that education was effective and the client is best prepared for discharge?