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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Correct Answer is B
Explanation
Methadone. Methadone is a synthetic opioid that can help reduce the symptoms of opioid withdrawal and prevent relapse.
Methadone acts on the same receptors as other opioids, but it has a longer duration of action and a lower potential for abuse. Methadone is given in controlled doses as part of an opioid treatment program.
The other choices are not correct because:
Choice A. Risperidone is an antipsychotic medication that has no effect on opioid withdrawal.
Choice C. Lithium carbonate is a mood stabilizer that is used to treat bipolar disorder and has no effect on opioid withdrawal.
Choice D. Disulfiram is a medication that inhibits the metabolism of alcohol and causes unpleasant reactions when alcohol is consumed. It has no effect on opioid withdrawal.
Correct Answer is D
Explanation
"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.
Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.
Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.
Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.
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