A nurse is admitting a client who has an alcohol use disorder. Which of the following actions should the nurse take first?

Determine the client's degree of physical dependence.

Discuss the treatment plan with the client.

Document the client's alcohol use in the medical record.

Initiate a referral for treatment for alcohol use disorder.

Answer and Explanation

The Correct Answer is C

A. Determine the client's degree of physical dependence:
This action is important but usually comes after the initial assessment and documentation. Assessing the degree of physical dependence involves evaluating the client's withdrawal symptoms, tolerance, and other physical health parameters. It helps in planning the appropriate level of care, such as detoxification if needed.

B. Discuss the treatment plan with the client:
While discussing the treatment plan is crucial, it's typically done after gathering essential information about the client's alcohol use, medical history, and current condition. The treatment plan is tailored based on the gathered data, which includes documenting the client's alcohol use.

C. Document the client's alcohol use in the medical record:
This is the first step because it provides a formal record of the client's alcohol use history, including patterns and any associated complications. Documenting this information helps in comprehensive care planning and ensures that all healthcare providers involved in the client's treatment have accurate and up-to-date information.

D. Initiate a referral for treatment for alcohol use disorder:
Referrals are essential, but they usually follow the initial assessment and documentation. The referral process involves connecting the client with appropriate resources, such as addiction specialists, counselors, or support groups, based on the documented information and the client's needs.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I will learn how to voluntarily control my blood pressure and heart rate."
This statement indicates the client might be referring to techniques such as biofeedback or relaxation exercises that involve controlling physiological responses consciously. While these are relaxation techniques, they are not specifically cognitive reframing. Cognitive reframing focuses on changing negative thought patterns.

B. "I will practice replacing negative thoughts with positive self-statements."
This statement accurately reflects the concept of cognitive reframing. It involves identifying negative or unhelpful thoughts and consciously replacing them with positive, empowering, or rational thoughts. This technique is widely used in cognitive-behavioral therapy (CBT) to help individuals manage stress, anxiety, and various mental health issues.

C. "I will focus on a mental image while concentrating on my breathing."
This statement describes a relaxation technique where individuals visualize a calming image and synchronize their breathing with this mental image. While this practice is beneficial for relaxation, it is not cognitive reframing. Cognitive reframing specifically deals with changing the content of thoughts, not necessarily focusing on mental imagery.

D. "I will progressively relax each of my muscle groups when feeling stressed."
This statement describes a relaxation technique known as progressive muscle relaxation. It involves tensing and then relaxing different muscle groups to reduce physical tension and stress. While this technique is excellent for relaxation, it is not cognitive reframing. Cognitive reframing pertains to changing thoughts, not physical sensations.

A. "Since injuring my knee. I've decided to become the team manager." B. "Since my mom died, I focus all my attention on my grades." C. “I didn't tell the teacher about the bullying because it wouldn't have changed anything." D. "I'm not even going to think about writing that thesis paper until after prom."

Correct Answer is A

Explanation

A. "Since injuring my knee, I've decided to become the team manager."
Option A represents an adaptive use of the ego defense mechanism known as sublimation. Sublimation is a process in which a person channels potentially negative or harmful impulses or feelings into more socially acceptable and constructive activities. In this case, the adolescent with the injured knee is using the opportunity to become the team manager, which is a positive and constructive way to stay engaged with the team despite the setback of the injury.

B. "Since my mom died, I focus all my attention on my grades."
This is an example of reaction formation, a defense mechanism where someone overemphasizes the opposite of their true feelings. In this case, the individual might be hiding or avoiding their grief by focusing on grades.

C. "I didn't tell the teacher about the bullying because it wouldn't have changed anything."
This is an example of rationalization, where the individual provides a logical-sounding but potentially inaccurate explanation for their actions. It can be a defense mechanism to justify or make more acceptable one's choices.

D. "I'm not even going to think about writing that thesis paper until after prom."
This is an example of procrastination or avoidance, which is not an ego defense mechanism but a coping or time-management strategy. It doesn't represent an adaptive use of a defense mechanism in this context.

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 is admitting a client who has an alcohol use disorder. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is leading a therapy session for a group of adolescent clients. Which of the following statements should the nurse identify as an adaptive use of ego defense mechanisms?

Correct Answer is A

Explanation

A nurse in a community health facility is interviewing a client who recently lost his job. The client states. "I was fired because my boss doesn't like me." Which of the following defense mechanisms is the client displaying?

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

A nurse is reviewing the laboratory results of an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect?

A nurse is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

A nurse is preparing to administer medications to a newly admitted client who has schizophrenia and is experiencing psychosis. Which of the following medications should the nurse plan to administer?