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","D","E"]

Explanation

Choice A reason: A matter-of-fact approach is effective for clients with schizotypal personality disorder as it helps in dealing with their eccentric behaviors and distorted thinking without reinforcing their odd beliefs.

Choice B reason: Clients with avoidant personality disorder may benefit more from a supportive and encouraging approach due to their sensitivity to rejection and feelings of inadequacy.

Choice C reason: For narcissistic personality disorder, a matter-of-fact approach might not be as effective because these clients often require admiration and may not respond well to a straightforward style.

Choice D reason: An antisocial personality disorder client may respond better to a matter-of-fact approach as it sets clear boundaries and expectations without emotional engagement, which they may exploit.

Choice E reason: Paranoid personality disorder clients may find a matter-of-fact approach beneficial as it provides clear and direct communication, which can help reduce their suspicions.

A. Honor commitments to the client and be on time for scheduled appointments. B. Initiate the interaction with superficial social conversation. C. Use humor when interacting with the client. D. Include the client when developing a plan of care. E. Use a formal businesslike approach with the client.

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

Explanation

Choice A reason: Honoring commitments and punctuality are fundamental in building trust, especially with clients who may have trust issues due to paranoid personality disorder.

Choice B reason: Superficial social conversation may not be effective in fostering trust with a client who has paranoid personality disorder, as they may perceive it as insincere.

Choice C reason: Using humor can be misinterpreted and may not be appropriate when working with clients who have paranoid personality disorder, as they might suspect ulterior motives.

Choice D reason: Including the client in the development of their plan of care is crucial as it gives them a sense of control and involvement, which can foster trust.

Choice E reason: A formal businesslike approach can provide a sense of professionalism and boundaries, which can help in building trust with a client who has paranoid personality disorder.

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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

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

Explanation

The nurse is working to develop a therapeutic nurse-client relationship with a client diagnosed with paranoid personality disorder. Which techniques will the nurse use to foster trust? Select all that apply.

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

Explanation

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