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:

Individuals with Paranoid Personality Disorder often exhibit distrust and suspicion of others. A matter-of-fact approach is beneficial as it avoids emotional engagement that could be perceived as threatening or deceitful. This approach helps in maintaining clear boundaries and reduces the potential for misunderstanding or paranoia.

Choice B reason:

For those with Avoidant Personality Disorder, a matter-of-fact approach might not be as effective because these individuals are often sensitive to negative evaluation and rejection. They may require a more supportive and encouraging approach to help them feel more comfortable in social interactions.

Choice C reason:

People with Schizotypal Personality Disorder display eccentric behaviors and have difficulty forming close relationships. A matter-of-fact approach can provide structure and clarity without overwhelming them with emotional intensity, which they may find difficult to process.

Choice D reason:

Individuals with Narcissistic Personality Disorder may not respond well to a matter-of-fact approach as they often have an inflated sense of self-importance and a need for admiration. They may perceive this approach as dismissive or not adequately acknowledging their perceived self-worth.

Choice E reason:

Those diagnosed with antisocial personality disorder tend to disregard the rights of others and may manipulate or treat others harshly. A matter-of-fact approach is useful as it sets clear expectations and limits, which is necessary to manage potentially manipulative or harmful behaviors.

A. "This is a good time to make a lot of serious changes in my life, such as a new job." B. "I will be able to maintain sobriety by looking at the long-term outcomes." C. "In order to give myself the best chance for sobriety, I will abstain from alcohol." D. "Now that I have completed rehab, I can safely return to life as it was before."

Correct Answer is C

Explanation

Choice A reason: Making significant life changes immediately after rehab can be overwhelming and might not be advisable as the client adjusts to sobriety.

Choice B reason: Focusing on long-term outcomes can be motivating, but it is also important to have short-term goals to maintain sobriety.

Choice C reason: Abstaining from alcohol is a fundamental part of maintaining sobriety and indicates an understanding of the importance of avoiding triggers.

Choice D reason: Returning to life as it was before rehab can be risky without making changes to support sobriety, such as avoiding triggers and continuing therapy.

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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

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

Explanation

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Correct Answer is C

Explanation

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