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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Identifying the client's support systems is an important aspect of the assessment, as support systems can play a crucial role in the client's recovery. However, it is not the highest priority during the initial assessment. Support systems can provide emotional, social, and sometimes financial assistance, which can be beneficial in managing a situational crisis.
Choice B reason:
Identifying the client's coping skills is also important because it helps the nurse understand how the client typically deals with stress and crises. Coping skills are mechanisms that individuals use to manage stressful situations and can include problem-solving, seeking support, and using relaxation techniques. However, this is not the highest priority during the initial assessment.
Choice C reason:
Asking the client to identify the cause of the crisis can provide valuable information about the client's perspective and insight into the situation. Understanding the cause can help in planning appropriate interventions. However, this is not the highest priority during the initial assessment, especially if the client is not in a stable condition to discuss the crisis.
Choice D reason:
Determining if the client has psychotic thinking, is the highest priority. Psychotic thinking can include delusions, hallucinations, and disorganized thoughts, which may indicate a severe mental health condition that requires immediate attention. It is essential to assess for psychotic symptoms to ensure the safety of the client and others, as well as to determine the need for urgent psychiatric intervention.
Correct Answer is A
Explanation
Choice A reason:
Respiratory depression/arrest is a well-documented risk associated with heroin use. Heroin is an opioid that can significantly depress the central nervous system, leading to slowed or stopped breathing. This can result in hypoxia, a condition where not enough oxygen reaches the brain, which can be fatal.
Choice B reason:
Acute pancreatitis is not typically associated directly with heroin use. While substance use can lead to various health complications, acute pancreatitis is more commonly associated with alcohol abuse rather than opioids like heroin.
Choice C reason:
Nasal septum perforation is a potential risk for individuals who snort heroin. The repeated irritation and damage to the mucosal tissues in the nose can lead to a perforation of the nasal septum, the tissue that separates the nasal passages.
Choice D reason:
Permanent short-term memory loss is not a commonly reported direct effect of heroin use. While chronic use of heroin can lead to cognitive deficits and deterioration of white matter in the brain, which affects decision-making and behavior regulation, it does not specifically cause permanent short-term memory loss.
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