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. Intellectualization: Intellectualization involves using logic or reasoning to avoid emotional response to stress, but it is not the defense mechanism demonstrated here. The client is not using abstract thinking to avoid feelings but justifying behavior.

B. Introjection: Introjection involves internalizing the beliefs or values of others, which is not what is happening in this scenario. The client is not adopting someone else’s values but rationalizing their own actions.

C. Rationalization: Rationalization is the defense mechanism the client is using. The client is justifying their drinking as a way to cope with stress, making the behavior seem reasonable or acceptable even though it may be harmful.

D. Repression: Repression involves unconsciously blocking out uncomfortable thoughts or feelings, but the client is not denying their emotions or thoughts about stress. Instead, they are justifying their behavior, which aligns more with rationalization.