A nurse is reviewing provider prescriptions for a client who is experiencing alcohol withdrawal.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first

dropdown

followed by

dropdown

.

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.

A. Transfer a client who has delirium from a bed to a wheelchair: Assisting with transfers and mobility is within the scope of practice for an AP, especially if the client is stable and the task does not require clinical decision-making.

B. Inform a client who has schizophrenia about available community services: This task requires clinical judgment and communication skills to ensure that the client understands the information and that the services are appropriate for their needs. It should be performed by a nurse, not an AP.

C. Obtain a list of current medications from a client who is experiencing a manic episode: While obtaining a medication list is an important task, it requires assessment and evaluation of the client's condition, which should be done by a nurse, especially when the client is in a manic state and may have impaired judgment or communication.

D. Insert an NG tube for a client who has acetaminophen toxicity: Inserting an NG tube is an invasive procedure that requires clinical knowledge and skill. It should be performed by a licensed nurse or physician, not an AP.