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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.
B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.
C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.
D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.
Correct Answer is A
Explanation
A. Encourage participants to express conflicts and work toward resolution:
Explanation: During the working phase of therapy, the nurse encourages participants to express their conflicts, fears, and concerns openly. The working phase is characterized by active participation and problem-solving. Encouraging clients to express their feelings and conflicts helps them work through their issues and promotes resolution. It's a crucial step in the therapeutic process, allowing clients to explore their emotions and gain insight into their anxieties.
B. Inform participants about principles for listening to and respecting each other:
Explanation: Setting ground rules for respectful communication is typically done in the initial or pre-working phase of therapy. While maintaining a respectful environment is important throughout the therapeutic process, it's not specific to the working phase.
C. Suggest that participants reflect on their progress as individuals and as a group:
Explanation: Reflection and assessment of progress can occur throughout therapy, not just in the working phase. It's essential for clients to evaluate their progress, but this action is not exclusive to the working phase.
D. Ask participants to become acquainted with and talk to each other:
Explanation: Building rapport and getting acquainted with other group members often occurs in the initial phase of therapy. During the working phase, the focus shifts more toward discussing and resolving specific issues and conflicts rather than introductory activities.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.