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.

Answer and Explanation

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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Correct Answer is D

Explanation

The client should expect hand tremors to start less than 24 hours after they stop drinking when reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder.

Choice A, "Disulfiram will prevent my cravings for alcohol," is incorrect because disulfiram works by creating a very unpleasant reaction when the client drinks alcohol and is not a medication for preventing cravings.

Choice B, "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage," is incorrect because Vitamin C is not indicated for liver disease related to alcohol use disorder and is not effective in preventing it.

Choice C, "Withdrawal symptoms should last about 5 to 7 days once they begin," is incorrect because withdrawal symptoms can last for several days or even weeks, depending on the severity of the alcohol use disorder.

A. Assure that child has a large variety of caregivers. B. Establish a reward system for positive behavior. C. Provide a flexible schedule to adjust to the child's interests. D. Allow for imaginative play with peers without supervision.

Correct Answer is B

Explanation

The nurse should recommend establishing a reward system for positive behavior when contributing to the plan of care for a child with an autism spectrum disorder. Reward systems can be particularly effective for children with autism spectrum disorder, as they respond well to structured routines and consistency.

Choice A, assuring that the child has a large variety of caregivers, is not recommended, as children with autism spectrum disorder can be particularly sensitive to changes in routine and caregivers. Providing a flexible schedule to adjust to the child's interests,

choice C may be appropriate in some cases, but a structured routine can be even more beneficial. Allowing for imaginative play with peers without supervision, choice D, may not be safe or effective in all situations. It is important for the nurse to work with the child, their family, and other healthcare professionals to develop an individualized plan of care that meets the child's specific needs and goals.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a child who has autism spectrum disorder. Which of the following interventions should the nurse recommend for the plan of care?

Correct Answer is B

Explanation

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