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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Naltrexone:
Naltrexone is an opioid receptor antagonist. It blocks the effects of opioids and alcohol in the brain. It's often used as part of a long-term treatment plan to prevent relapse in individuals who have already stopped drinking and are trying to maintain sobriety. Naltrexone does not directly manage acute alcohol withdrawal symptoms. Instead, it helps individuals reduce or quit drinking over the long term by reducing the pleasure associated with alcohol consumption.
B. Disulfiram:
Disulfiram is an aversion therapy medication used as a deterrent to drinking. When someone taking disulfiram consumes alcohol, it causes unpleasant physical reactions, such as nausea, flushing, and palpitations. This discourages individuals from drinking while they are on the medication. Disulfiram is not used to manage acute withdrawal symptoms but rather serves as a deterrent to drinking for individuals who are trying to maintain sobriety.
C. Lorazepam:
Lorazepam is a benzodiazepine medication that acts as a central nervous system depressant. It is commonly used to manage acute alcohol withdrawal symptoms. Benzodiazepines like lorazepam help to reduce anxiety, agitation, and the risk of seizures associated with alcohol withdrawal. They are typically used in a controlled manner to provide relief during the acute phase of withdrawal.
D. Acamprosate:
Acamprosate is used in the maintenance phase of alcohol use disorder treatment. It helps individuals maintain abstinence by stabilizing the chemical imbalances in the brain that occur after prolonged alcohol use. Acamprosate is not used for acute withdrawal management but is instead prescribed to support individuals who have already stopped drinking and are trying to avoid relapse over the long term.
Correct Answer is B
Explanation
A. Displacement:
Displacement is a defense mechanism where a person redirects their feelings, often negative or hostile ones, from the original source or target to a different, less threatening target. For example, if the client were to express anger at their boss by yelling at their family members instead, it would be an example of displacement.
B. Rationalization:
Rationalization is a defense mechanism in which a person provides logical or reasonable explanations to justify or explain a situation or behavior, even if these explanations are not entirely true or valid. It involves creating justifications or excuses to make an event or one's actions appear more reasonable or acceptable. In this case, the client is rationalizing the job loss by attributing it to their boss not liking them, which may be an oversimplified or inaccurate explanation.
C. Dissociation:
Dissociation is a defense mechanism where a person mentally separates themselves from their own thoughts, feelings, or experiences to cope with overwhelming or traumatic situations. It involves a disconnection from reality. The client's statement doesn't suggest dissociation; rather, they are providing a reason for their job loss.
D. Repression:
Repression is a defense mechanism that involves the unconscious exclusion of painful or anxiety-provoking thoughts, feelings, or memories from awareness. It is not readily visible or expressed in behavior. The client's statement involves a conscious attempt to explain their job loss, so it's not an example of repression.
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