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 reason:
The statement "Alcohol tolerance causes me to have an increased effect when taking opiates" is incorrect. Alcohol tolerance refers to the body's diminished response to the effects of alcohol due to prolonged exposure. It does not directly affect the body's response to other substances like opiates. However, it's important to note that mixing alcohol with opiates can be dangerous and is generally advised against due to the risk of respiratory depression and other adverse effects.

Choice B reason:
The statement "I will develop a decreased physical response to alcohol" is correct and indicates effective teaching. As a person develops alcohol tolerance, their body requires more alcohol to achieve the same effects that were previously attained with less alcohol. This is due to physiological adaptations within the body, particularly in the liver and central nervous system, which become more efficient at metabolizing alcohol and less responsive to its effects.

Choice C reason:
The statement "Alcohol tolerance is a medical emergency and can develop as a result of withdrawal" is incorrect. Alcohol tolerance itself is not a medical emergency; rather, it is a physiological adaptation to regular alcohol consumption. Withdrawal, on the other hand, can be a medical emergency if severe symptoms such as seizures or delirium tremens occur. Tolerance and withdrawal are related but distinct phenomena; tolerance can lead to dependence, which, when alcohol use is stopped, can result in withdrawal symptoms.

Choice D reason:
The statement "Alcohol tolerance produces physical changes when I haven't recently ingested alcohol" is misleading. Alcohol tolerance does not produce physical changes in the absence of alcohol. Instead, tolerance is characterized by a reduced response to alcohol when it is consumed. Physical changes, such as withdrawal symptoms, may occur when a person who has developed tolerance stops consuming alcohol, but these are not due to tolerance itself.

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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Naxlex Comprehensive Predictor Exams

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