A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

Risk for aspiration related to impaired gag reflex.

Risk for injury related to impaired coordination and judgment.

Impaired liver function related to alcohol toxicity.

Risk for falls related to dizziness and unsteady gait.

Risk for infection related to impaired immune function.

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A Reason:
Aspiration is a significant risk for clients with acute alcohol intoxication due to an impaired gag reflex. Alcohol can depress the central nervous system, leading to a decreased level of consciousness and a diminished gag reflex, which increases the risk of aspiration of gastric contents into the lungs.

Choice B Reason:
Impaired coordination and judgment are common in acute alcohol intoxication, increasing the risk of injury. Alcohol affects the cerebellum, the part of the brain that regulates coordination and balance, as well as the frontal lobes, which are responsible for judgment and decision-making.

Choice C Reason:
Alcohol is metabolized by the liver, and excessive alcohol intake can lead to alcohol toxicity and liver impairment. Acute alcohol intoxication can cause hepatic steatosis, alcoholic hepatitis, and even acute liver failure in severe cases.

Choice D Reason:
Dizziness and an unsteady gait are direct effects of alcohol's impact on the vestibular system and the brain's ability to process spatial information, leading to an increased risk of falls.

Choice E Reason:
Alcohol intoxication can impair immune function, making the client more susceptible to infections. Alcohol disrupts immune pathways in complex ways, which can impair the body's ability to defend against infections

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Correct Answer is B

Explanation

Choice A: "I can't call a doctor in the middle of the night unless it's an emergency."
This response may seem reasonable, but it could escalate the situation if the client feels their concerns are not being taken seriously. It's important to validate the client's feelings and find a solution that respects both their needs and the realities of the situation.

Choice B: "You must be very upset about something."
This response validates the client's feelings and opens up a dialogue. It shows empathy and understanding, which can help de-escalate the situation.

Choice C: "Go back to your room, and I'll try to get in touch with your doctor."
This response acknowledges the client's request and provides a clear action plan. However, it's important to follow through on this promise to maintain trust.

Choice D: "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and likely to escalate the situation. It's important to remain calm and professional, even when dealing with difficult behavior.

A. Enroll the client in a nutritional class on the unit. B. Weigh the client at the same time every morning. C. Ask the provider to arrange a consultation with the facility chaplain. D. Sit with the client during meals and snacks.

Correct Answer is D

Explanation

Choice A reason:
Enrolling the client in a nutritional class can be beneficial for long-term nutritional education, but it may not have an immediate impact on the client's current state of malnutrition and may not be feasible if the client is experiencing severe symptoms of depression.

Choice B reason:
Weighing the client at the same time every morning is a good practice for monitoring the client's weight, but it does not directly contribute to improving the client's nutritional status. It is more of a measurement and monitoring action rather than an intervention.

Choice C reason:
Arranging a consultation with the facility chaplain might address spiritual needs, which can be an important aspect of holistic care, but it does not directly improve nutritional status and is not the most immediate concern for a client with malnutrition.

Choice D reason:
Sitting with the client during meals and snacks can encourage food intake and provide an opportunity for the nurse to offer support and encouragement. This direct intervention can help improve the client's nutritional intake, which is essential for addressing malnutrition.

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A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

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