A nurse is performing a home visit on a client who has Alzheimer's disease and their partner. The partner states, "I wish I had some time to myself and run errands, but I need to be here all the time." Which of the following referrals should the nurse recommend to the client's partner?

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.

Rationale for correct choices:

• Irritability: Irritability is a common symptom of posttraumatic stress disorder (PTSD), often resulting from the heightened arousal and anxiety that individuals with PTSD experience after trauma. This is frequently seen in clients who have undergone significant emotional distress.
• Feelings of emptiness: A sense of emptiness or detachment is often associated with PTSD. This is related to the emotional numbness and avoidance that individuals may experience as a result of trauma, leading them to feel disconnected or emotionally "empty."
• Sleep disturbance: Sleep problems, such as insomnia or nightmares, are hallmark symptoms of PTSD. Clients often struggle with restful sleep due to anxiety, hypervigilance, or intrusive thoughts related to the traumatic event.
• Guilt: Guilt is a common emotion experienced by individuals with PTSD, especially following trauma such as sexual assault. Survivors may blame themselves for not preventing the event, which can contribute to their emotional distress and symptoms of PTSD.

Rationale for incorrect choices:

• Hallucinations: Hallucinations are not typically associated with PTSD. While PTSD can cause intense emotional reactions, hallucinations are more commonly seen in conditions such as schizophrenia or severe substance intoxication, not in PTSD.
• Echopraxia: Echopraxia, which involves mimicking another person's movements, is generally associated with conditions such as autism or certain neurological disorders, not PTSD.