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A nurse is caring for a client who was admitted for alcohol use disorder, which of the following findings require follow-up by the nurse? Select all that apply.

Genitourinary assessment

Client's recent loss

Smoking history

Client's recent consumption of alcohol

Gastrointestinal assessment

Respiratory assessment

Neurological assessment

Blood alcohol level

Cardiac assessment

Answer and Explanation

Correct Answer : B,D,E,G,H

Rationale for correct choices:

Client's recent loss: The recent death of the client's parents is a critical factor in the client's relapse into alcohol use. This significant emotional stress can exacerbate substance use and affect the client's mental and physical health, requiring close monitoring and support.
Client's recent consumption of alcohol: The client's last drink was estimated to be 2 hours ago, and they are currently intoxicated with a blood alcohol level (BAC) of 310 mg/dL. This level is dangerously high, requiring immediate observation for signs of alcohol toxicity.
Gastrointestinal assessment: The client reports weight loss and minimal appetite, which may be indicative of alcohol-related damage to the gastrointestinal system, such as gastritis or liver disease. This warrants a thorough assessment to address any underlying issues.
Neurological assessment: The client is intoxicated and has slurred speech, indicating impaired neurological functioning. Additionally, alcohol use disorder can lead to long-term neurological impairments, such as cognitive deficits, which require careful monitoring during withdrawal.
Blood alcohol level: A blood alcohol level of 310 mg/dL is critically elevated and requires urgent follow-up. This level is significantly above the normal range and indicates severe intoxication, which can lead to life-threatening complications such as respiratory depression or coma.

Rationale for incorrect choices:

Genitourinary assessment: There are no immediate concerns related to the client's genitourinary system based on the provided information. The client did not report any issues or symptoms in this area.
Smoking history: Although smoking history is important in overall health assessments, the client's current concerns (alcohol use disorder, recent loss, intoxication) take priority over the 20 years ago smoking history in this situation.
Respiratory assessment: The client's respiratory rate is 10/min, which is low but not immediately alarming in the context of alcohol intoxication. Close monitoring is required, but there is no urgent indication of respiratory distress at this time. The client ‘s respiratory examination is normal as well as SPO2.
Cardiac assessment: The client's heart rate and blood pressure are within normal limits, and there is no indication of acute cardiac distress. Therefore, a cardiac assessment does not require immediate follow-up unless other symptoms develop.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for correct choices:

Remaining neutral: The nurse should remain neutral to avoid reinforcing or escalating the client’s grandiose beliefs. This helps maintain trust and creates space for self-reflection without judgment.
Explaining that the client is not entitled to play on a professional team: Gently addressing the client’s unrealistic expectations helps them understand the reality of their situation and fosters a more grounded perspective on their goals.

Rationale for incorrect choices:

Questioning the client's abilities: Directly questioning the client's abilities could be seen as confrontational and may increase defensiveness. A more constructive approach would focus on challenging unrealistic beliefs.
Challenging the client's feelings of grandiosity: Challenging grandiosity directly can make the client feel attacked. It’s better to educate and explain the reality of their expectations in a supportive way.
Supporting the client's fear of abandonment: The client does not appear to express abandonment fears in this case. The issue is more related to grandiosity, so focusing on this would be more effective.
Suggesting another sport: Suggesting a different sport might divert attention from the core issue—grandiosity. Addressing the client's distorted self-image is more important before offering alternatives.

A. Has a history of gastric reflux B. Has a history of cholelithiasis C. Drinks a glass of orange juice daily D. Takes St. John's Wort daily

Correct Answer is D

Explanation

A. Has a history of gastric reflux: Gastric reflux is not a contraindication for selegiline transdermal. This medication is primarily concerned with interactions that may affect the central nervous system or blood pressure, rather than gastric issues.

B. Has a history of cholelithiasis: A history of gallstones (cholelithiasis) is not a contraindication for selegiline transdermal. This medication does not have a known direct effect on the gallbladder or bile ducts.

C. Drinks a glass of orange juice daily: There is no significant interaction between selegiline and orange juice. Clients should, however, avoid tyramine-rich foods to prevent hypertensive crises, but orange juice is not a concern in this case.

D. Takes St. John's Wort daily: This is a contraindication. Selegiline is a monoamine oxidase inhibitor (MAOI), and taking it in combination with St. John's Wort can increase the risk of serotonin syndrome, a potentially life-threatening condition. This interaction should be avoided.

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Body system	Findings
Neurological	Impaired cognition Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Tremulousness Malaise

A nurse is caring for a client who was admitted for alcohol use disorder, which of the following findings require follow-up by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the student health clinic is caring for a client Exhibits Complete the following sentence by using the lists of options. The nurse should care for the client by dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

A nurse is reviewing the medical record of a client who has a new prescription for selegiline transdermal. Which of the following findings should the nurse identify as a contraindication for administration of this medication to the client?

Correct Answer is D

Explanation

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