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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This statement is accurate and reflects effective teaching. Bupropion, like many antidepressants, can take several weeks to reach its full therapeutic effect. Informing patients about this delay is important to set realistic expectations and to encourage adherence to the medication regimen.
Choice B reason:
This statement is not entirely accurate. While moderate alcohol consumption may be permissible for some patients taking bupropion, it is generally advised to avoid or limit alcohol intake due to the risk of seizures and other side effects. Alcohol can also worsen depression symptoms and interact with the medication.
Choice C reason:
This statement is incorrect. Bupropion does not typically cause bradycardia (slow heartbeat). Instead, it can cause tachycardia (fast heartbeat) as a side effect. Patients should be informed about the potential cardiovascular effects of bupropion, including an increased heart rate.
Choice D reason:
This statement is incorrect. Increased salivation and drooling are not common side effects of bupropion. The medication is more commonly associated with dry mouth. Effective teaching would include informing the patient about the more likely side effects, such as dry mouth, insomnia, and headaches.
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.
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