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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.
Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.
Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.
Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.
Correct Answer is B
Explanation
Choice A: I will join a book club in my neighborhood.
Joining a book club in the neighborhood can be a good step towards socializing and overcoming the fear of open or crowded places. However, the success of this step largely depends on the severity of the client's agoraphobia.
Choice B: I plan to sit on a park bench for a few minutes each day.
This is a good practice as it involves gradual exposure to the outside world, which can help in managing agoraphobia. The client can start with a few minutes and then gradually increase the time spent outside.
Choice C: I should avoid entering elevators and other closed spaces.
Avoidance is not a solution for agoraphobia. In fact, avoiding places or situations out of fear can reinforce the phobia. The goal of treatment is to help the client face these situations rather than avoid them.
Choice D: I can try participating in group therapy every week.
Group therapy can be beneficial as it provides a supportive environment where the client can learn from the experiences of others dealing with the same issues. It can also help the client feel less isolated.
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