A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?
"My boss fired me due to my frequent absence."
"My friends frequently drink alcohol, so I do not see them anymore."
"I have a sibling who attends Al-Anon”
"I take care of my parent who has Wernicke-Korsakoff syndrome."
The Correct Answer is C
A. "My boss fired me due to my frequent absence": This statement indicates a lack of support in the client's work environment, rather than a positive support system. Losing a job due to alcohol use suggests strained relationships and challenges in the client's social or professional life.
B. "My friends frequently drink alcohol, so I do not see them anymore": While the client is avoiding potentially harmful relationships, this statement indicates isolation rather than a supportive network.
C. "I have a sibling who attends Al-Anon": This statement indicates that the client has a family member actively involved in a support group (Al-Anon), which is designed for families and friends of individuals with alcohol use disorders. This suggests the client has a support system in place.
D. "I take care of my parent who has Wernicke-Korsakoff syndrome": While this indicates a sense of responsibility, it does not necessarily point to a supportive relationship. The client may be struggling with caregiving without the emotional or social support they need.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.
Correct Answer is C
Explanation
A. Venlafaxine and frequent yawning/weight loss: Frequent yawning and weight loss are not typical signs of an adverse reaction to venlafaxine. These symptoms can occur with various conditions, but they do not necessarily require withholding the medication.
B. Olanzapine and frequent urination: Frequent urination is not a known side effect of olanzapine. However, the nurse should assess the client for other factors contributing to this symptom. It may not be severe enough to require withholding the medication without further evaluation.
C. Fluoxetine and muscle rigidity/tachycardia: Muscle rigidity and tachycardia could indicate serotonin syndrome, a potentially life-threatening condition. This requires immediate intervention, and the medication should be withheld while notifying the provider for further evaluation and treatment.
D. Nortriptyline and nausea/dry mouth: Nausea and dry mouth are common side effects of tricyclic antidepressants like nortriptyline. These symptoms typically do not require withholding the medication, but the nurse should monitor the client for any worsening or additional adverse effects.
Complete the following sentence by using the lists of options.
The client is at risk of developing