A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Constipation

Dry skin

Hypotension

Urinary retention

Answer and Explanation

The Correct Answer is C

Choice A reason: Constipation isn’t a primary effect of disulfiram-alcohol reaction, which causes acetaldehyde buildup, triggering vasodilation and nausea, not gut motility issues. Scientifically, this reaction targets cardiovascular and systemic responses, lacking evidence for significant gastrointestinal stasis as a monitored outcome in this scenario.

Choice B reason: Dry skin isn’t linked to disulfiram-alcohol interaction, which induces flushing and sweating from acetaldehyde toxicity, not dehydration. Scientifically, the reaction affects vascular and autonomic systems, producing moist, not dry, skin responses, making this an unrelated finding for monitoring here.

Choice C reason: Hypotension occurs in disulfiram-alcohol reaction as acetaldehyde dilates vessels, dropping blood pressure. This cardiovascular effect, alongside tachycardia, is a key sign to monitor, aligning with scientific understanding of the drug’s inhibition of aldehyde dehydrogenase, causing systemic distress.

Choice D reason: Urinary retention isn’t a typical disulfiram-alcohol effect; the reaction focuses on vasodilation, nausea, and hypotension from acetaldehyde. Scientifically, autonomic overstimulation may occur, but bladder dysfunction isn’t a primary outcome, making this less critical to monitor than cardiovascular collapse.

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Correct Answer is B

Explanation

Choice A reason: Turning on overhead lights disrupts sleep by stimulating retinal photoreceptors, raising alertness via melatonin suppression. Scientifically, dim or red light preserves rest, making this contrary to reducing environmental stressors for sleep optimization in acute care settings.

Choice B reason: Rubber-soled shoes reduce noise from footsteps, minimizing auditory disturbances to sleep. Scientifically, quiet environments lower cortisol and enhance sleep quality, aligning with evidence-based stressor reduction strategies to promote rest in hospital clients effectively.

Choice C reason: Opening curtains increases light and noise exposure, disrupting sleep cycles via circadian misalignment. Scientifically, darkness supports melatonin production, so this heightens stressors, opposing the goal of improving rest in shared hospital rooms per sleep science.

Choice D reason: Shift reports near rooms raise noise levels, activating the hypothalamic-pituitary axis, disturbing sleep. Scientifically, quiet zones reduce awakenings, making this detrimental to stressor reduction, as it elevates auditory interference contrary to sleep promotion goals.

A. "You will suffer serious health issues if you don't take your medication." B. "Have you considered how your decision to refuse medication will affect your family?" C. "I'd like to hear your thoughts about giving yourself this medication." D. "Why don’t you want to learn how to give yourself your medication?"

Correct Answer is C

Explanation

Choice A reason: Threatening health consequences may escalate resistance in diabetes care. It dismisses feelings, reducing trust, and isn’t therapeutic for addressing refusal effectively.

Choice B reason: Guilt via family impact pressures the client, not exploring reasons. This approach hinders open dialogue, critical for diabetes self-management acceptance.

Choice C reason: Inviting thoughts fosters therapeutic communication, exploring barriers to insulin use. It respects autonomy, building trust essential for diabetes education and compliance.

Choice D reason: "Why" questions can feel confrontational, shutting down discussion. Open-ended inquiry better uncovers motivations in diabetes refusal, avoiding defensiveness.

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A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care facility is assisting with the development of an in-service about reducing environmental stressors to improve clients’ sleep. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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