A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Refer the client to a mental health care provider for evaluation and treatment.

Determine the presence and degree of suicidal risk.

Identify support groups in the community for long-term treatment.

Assist the client to identify negative effects of chemical dependency.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Referring the client to a mental health care provider is an important step, but it may not be the immediate priority. The referral process can be initiated once the client's immediate safety and acute needs are addressed.

Choice B reason:
Determining the presence and degree of suicidal risk is the priority nursing intervention. Clients with depressive disorders, especially those experiencing significant life stressors such as job loss and undergoing alcohol withdrawal, are at a higher risk for suicide. It is crucial to assess their risk and take appropriate measures to ensure their safety.

Choice C reason:
Identifying support groups is a valuable part of long-term treatment and recovery, but it is not the immediate priority. Support groups can provide ongoing assistance and a sense of community once the client is stable and ready to engage in long-term recovery.

Choice D reason:
Assisting the client to identify the negative effects of chemical dependency is an important aspect of treatment, but it is not the immediate priority. This intervention is part of the client's long-term recovery and education process.

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 ["A","C","D","E"]

Explanation

Choice A reason:
Cirrhosis is a severe scarring of the liver and poor liver function seen at the terminal stages of chronic liver disease. It is one of the primary long-term effects of alcohol use disorder, as the liver is the main organ responsible for metabolizing alcohol. Chronic alcohol consumption can lead to inflammation, liver cell death, and eventually cirrhosis, which significantly impairs the liver's ability to function properly.

Choice B reason:
Heightened awareness is not typically a long-term physiological effect of alcohol use disorder. In fact, chronic alcohol use is more likely to dull cognitive functions and reduce awareness due to its depressive effects on the central nervous system.

Choice C reason:
Gastritis, an inflammation of the stomach lining, is another potential long-term effect of alcohol use disorder. Alcohol can irritate and erode the gastric mucosa, leading to gastritis, which may present with symptoms such as abdominal pain, nausea, and vomiting.

Choice D reason:
Brain damage is a serious long-term effect of alcohol use disorder. Alcohol can cause changes in the brain, leading to problems with cognition, memory, and motor skills. Chronic exposure to alcohol can result in brain shrinkage and the development of conditions like Wernicke-Korsakoff syndrome.

Choice E reason:
Esophageal varices are enlarged veins in the esophagus that can occur as a result of portal hypertension, often due to cirrhosis of the liver caused by alcohol use disorder. They are a significant risk because they can rupture and lead to life-threatening bleeding.

A. "Alcohol tolerance causes me to have an increased effect when taking opiates." B. "I will develop a decreased physical response to alcohol." C. "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal." D. "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol."

Correct Answer is B

Explanation

Choice A reason:
The statement "Alcohol tolerance causes me to have an increased effect when taking opiates" is incorrect. Alcohol tolerance refers to the body's diminished response to the effects of alcohol due to prolonged exposure. It does not directly affect the body's response to other substances like opiates. However, it's important to note that mixing alcohol with opiates can be dangerous and is generally advised against due to the risk of respiratory depression and other adverse effects.

Choice B reason:
The statement "I will develop a decreased physical response to alcohol" is correct and indicates effective teaching. As a person develops alcohol tolerance, their body requires more alcohol to achieve the same effects that were previously attained with less alcohol. This is due to physiological adaptations within the body, particularly in the liver and central nervous system, which become more efficient at metabolizing alcohol and less responsive to its effects.

Choice C reason:
The statement "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal" is incorrect. Alcohol tolerance itself is not a medical emergency; rather, it is a physiological adaptation to regular alcohol consumption. Withdrawal, on the other hand, can be a medical emergency if severe symptoms such as seizures or delirium tremens occur. Tolerance and withdrawal are related but distinct phenomena; tolerance can lead to dependence, which, when alcohol use is stopped, can result in withdrawal symptoms.

Choice D reason:
The statement "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol" is misleading. Alcohol tolerance does not produce physical changes in the absence of alcohol. Instead, tolerance is characterized by a reduced response to alcohol when it is consumed. Physical changes, such as withdrawal symptoms, may occur when a person who has developed tolerance stops consuming alcohol, but these are not due to tolerance itself.

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 caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a patient to the medical unit who has a history of alcohol use disorder. The nurse should be aware of which of the following potential long-term physiological effects on the patient's body? (Select all that apply)

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

Explanation

A nurse is reinforcing teaching about alcohol tolerance with a newly admitted client. Which of the following statements by the client indicates that the teaching was effective?

Correct Answer is B

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

The nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal symptoms. Which of the following should be the priority action by the nurse?

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?

A nurse is caring for a client who is prescribed extended-release Morphine. The nurse should recognize which of the following assessment cues as an indication of opioid overdose?