A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?
Identify the use of defense mechanisms.
Prevent the client from harming herself or others.
Support the client's coping skills.
The Correct Answer is B
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.
Choice C, supporting the client's coping skills, is not a priority intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.
Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.
Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.
Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.
Correct Answer is B
Explanation
Allow the client to exercise once per day for a set amount of time. It is important to set limits and boundaries for a client with anorexia nervosa to ensure their safety, but also to respect their autonomy.
Reminding the client of weight loss consequences (choice A) can be counterproductive, asking why they exercise frequently (choice C) is important, but not sufficient without setting boundaries, and allowing the client to exercise as long as they eat 50% of their meals (choice D) can be dangerous.
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