A nurse is caring for a client who has a history of alcohol use disorder and has been hospitalized for alcohol intoxication. The nurse enters the room and finds the client shouting "Get those bugs off of me." Which of the following responses should the nurse make?
"I'm sure that the bugs you see will not harm you."
"I don't see any bugs, but you seem very frightened."
"Let's get out of your room so that the bugs will not bother you
“There are no bugs in here. This is part of your illness."
The Correct Answer is B
A. "I'm sure that the bugs you see will not harm you.": This response validates the hallucination and may increase the client's anxiety.
B. "I don't see any bugs, but you seem very frightened.": This response maintains reality orientation while acknowledging the client’s emotional state, a therapeutic and non-confrontational approach.
C. "Let's get out of your room so that the bugs will not bother you": This reinforces the hallucination and may worsen disorientation.
D. “There are no bugs in here. This is part of your illness.": This is too blunt and dismissive, potentially increasing defensiveness or agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. drinking it cold: Temperature does not significantly influence alcohol absorption. The rate is not increased by consuming cold beverages.
B. an empty stomach: Without food, alcohol passes quickly into the small intestine where it is rapidly absorbed into the bloodstream, increasing its effects.
C. drinking it warm: Warm temperature may slightly increase vasodilation but does not significantly affect absorption rate compared to stomach contents.
D. drinking large amounts: Drinking more increases alcohol concentration but does not increase absorption rate per unit; rather, it may saturate metabolic pathways.
Correct Answer is B
Explanation
A. "This medication will cure alcohol use disorder.”
Disulfiram does not cure alcohol use disorder. It is a deterrent that causes unpleasant effects when alcohol is consumed, supporting abstinence.
B. "Avoid alcohol for 2 weeks after discontinuing the medication.”
Disulfiram inhibits aldehyde dehydrogenase. Its effects persist for up to 2 weeks after stopping, so alcohol must be avoided during this time.
C. "You can safely use topical products that contain alcohol, such as cologne."
False. Even topical alcohol-containing products (cologne, aftershave, hand sanitizers) can trigger a disulfiram reaction.
D. "You should avoid eating undercooked meats while taking this medication."
There is no known interaction between disulfiram and undercooked meat.
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