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: Pointing toes eases stocking application, reducing drag on skin. Scientifically, this aligns with proper technique, enhancing venous return without resistance, so no intervention is needed, as it supports effective antiembolic function per guidelines.

Choice B reason: Creases on the front risk pressure sores or impaired circulation, countering antiembolic goals. Scientifically, smooth application prevents venous stasis, requiring intervention, as this error compromises blood flow and skin integrity in at-risk clients.

Choice C reason: Turning stockings inside out aids application, a standard technique for even fit. Scientifically, this ensures proper compression gradient, supporting venous return, so no intervention is warranted, as it’s correct per procedural evidence.

Choice D reason: Applying before getting out of bed maximizes compression benefits, reducing clot risk. Scientifically, this aligns with prophylaxis timing, as gravity aids swelling post-ambulation, making it appropriate and not requiring nurse intervention.

A. Persistent uterine contractions B. Increased fetal movement C. Rigid abdomen D. Bright red vaginal bleeding

Correct Answer is D

Explanation

Choice A reason: Persistent contractions signal labor or abruption, not previa. Placenta previa causes painless bleeding from placental positioning, not uterine activity.

Choice B reason: Increased fetal movement isn’t tied to previa; it’s a fetal response indicator. Previa’s hallmark is maternal bleeding, not fetal behavior changes.

Choice C reason: Rigid abdomen suggests abruption with clot formation, not previa. Previa bleeding is external, leaving the uterus soft, not tense.

Choice D reason: Bright red vaginal bleeding is classic in placenta previa, from low placental implantation. It’s painless, distinguishing it from other complications.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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