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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale for correct choice:
- Determine the client's level of anxiety to check for the risk of self-harm: Assessing the client’s anxiety is vital in identifying any risk of self-harm or suicidal thoughts, especially after trauma. This helps the nurse provide appropriate interventions to ensure the client's safety.
Rationale for incorrect choices:
- Tell the client their consent is not required prior to collecting potential physical evidence: The nurse must obtain the client’s consent before collecting any physical evidence. Consent is a legal and ethical requirement, especially in cases of sexual assault.
- Ask the client if they often walk alone when out in public places: This question may inadvertently lead to feelings of guilt or self-blame and is not an immediate priority. The focus should be on addressing the trauma and the client's current needs.
- Avoid asking the client open-ended questions during the interview: Open-ended questions allow the client to express their feelings and experiences, which is essential in trauma care. Avoiding them could hinder the client’s ability to share and may limit the nurse’s understanding of the situation.
Correct Answer is B
Explanation
A. Minimize time spent gambling each week: While reducing time spent gambling can be helpful, the focus should be on addressing the underlying behaviors and emotions related to the gambling disorder. A more holistic approach is typically more effective.
B. Encourage the client to participate in a self-help group: Self-help groups, such as Gamblers Anonymous, provide valuable support for individuals with gambling disorders. These groups offer shared experiences and coping strategies, making them a crucial part of the treatment plan.
C. Ask the client why they are unable to stop gambling: Asking "why" may feel confrontational or non-supportive. Instead, the nurse should use therapeutic communication to explore the client’s thoughts and feelings in a non-judgmental way.
D. Obtain a prescription for memantine: Memantine is used to treat Alzheimer's disease and other cognitive disorders, not gambling disorder. Medications are not typically the primary treatment for gambling disorder; instead, therapy and behavioral interventions are applied.
Complete the following sentence by using the lists of options.
The client is at risk of developing