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

Explanation

Choice A reason: Wernicke-Korsakoff syndrome is a brain and memory disorder that requires immediate treatment. It occurs due to a severe deficiency of thiamine (vitamin B1), which is essential for the brain to convert food into energy.

Choice B reason: There is no evidence suggesting that Wernicke-Korsakoff syndrome is a psychological condition related to stress.

Choice C reason: Wernicke-Korsakoff syndrome is not a genetic disorder; it is caused by a deficiency of vitamin B1, often associated with alcohol abuse or malnutrition.

Choice D reason: It is not an infectious disease; Wernicke-Korsakoff syndrome results from nutritional deficiencies, specifically a lack of thiamine (vitamin B1).

A. Exploring B. Silence C. Voicing doubt D. Challenging E. Disapproving F. Agreeing

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

Explanation

Choice A reason: Exploring is a therapeutic technique that involves delving into a client's experiences and feelings, which can be beneficial in understanding their perspective.

Choice B reason: Silence can be a therapeutic technique that gives clients space to think and express themselves.

Choice C reason: Voicing doubt can undermine the client's confidence and is not considered a therapeutic response.

Choice D reason: Challenging may confront the client in a non-therapeutic way, potentially leading to defensiveness.

Choice E reason: Disapproving can make clients feel judged and is not conducive to a therapeutic relationship.

Choice F reason: Agreeing may not always be therapeutic as it can prevent clients from exploring all aspects of their issues.

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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.

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What is Wernicke-Korsakoff syndrome?

Correct Answer is A

Explanation

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.

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

Explanation

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