A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Client reports limiting alcohol consumption

Participation in group therapy

Appetite

Cognition

Vital signs

Movement through the stages of grief

Answer and Explanation

Correct Answer : B,C,D,E

Choice A: Client reports limiting alcohol consumption
While reporting a reduction in alcohol consumption is a positive sign, it is not as strong an indicator of progress as actual participation in structured treatment programs like group therapy. Self-reported data can sometimes be unreliable, especially in individuals with a history of substance use disorders.
Choice B: Participation in group therapy
Participation in group therapy is a significant indicator of progress. Group therapy provides a supportive environment where clients can share experiences, gain insights, and receive encouragement from peers. It also helps in building coping strategies and reducing feelings of isolation.
Choice C: Appetite
Improvement in appetite is a good indicator of physical recovery and overall well-being. Alcohol use disorder often leads to poor nutrition and weight loss, so an increase in appetite suggests that the client’s body is beginning to recover and that they are likely consuming more nutritious food.
Choice D: Cognition
Improved cognition indicates that the client is recovering from the neurological effects of alcohol intoxication. This includes better clarity of thought, improved memory, and the ability to respond coherently to questions. Cognitive recovery is crucial for the client to engage effectively in therapy and other treatment activities.
Choice E: Vital signs
Stabilized vital signs are a clear indicator of physical recovery. On admission, the client had a high blood
Choice F: Movement through the stages of grief
While moving through the stages of grief is important for emotional recovery, it is a more subjective measure and can vary greatly among individuals. It is not as directly measurable as the other indicators listed.

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Correct Answer is C

Explanation

Choice A reason:
While it is important for a social worker to be aware of a client's difficulty with remembering prescribed food restrictions, this information is more relevant to the dietary staff or a nutritionist who can assist with meal planning and education. However, if the memory issues are severe and impact the client's ability to live independently, then it would also be pertinent for the social worker.

Choice B reason:
Frustration with finding an activity to relieve restless energy may be relevant to a social worker if it pertains to the client's overall mental health and well-being. The social worker can collaborate with the healthcare team to find suitable activities or therapies that can help the client manage their energy levels.

Choice C reason:
The inability of the client to return home after discharge is critical information for a social worker. This directly impacts the client's need for support services, such as long-term care planning, home health services, or alternative living arrangements. The social worker plays a key role in coordinating these services and ensuring a smooth transition from the hospital to the next phase of care.

Choice D reason:
A request to talk to someone about changes in spiritual beliefs is also relevant to the social worker, as they can provide or arrange for spiritual support services. However, this is not as urgent as the need for housing or care planning, which has immediate practical implications for the client's discharge planning.

A. Gastrointestinal assessment B. Smoking history C. Blood alcohol level D. Client’s recent loss E. Genitourinary assessment F. Client’s recent consumption of alcohol G. Neurological assessment H. Cardiac assessment I. Respiratory assessment

Correct Answer is ["A","C","D","F","G"]

Explanation

Choice A: Gastrointestinal assessment
The client reports weight loss and minimal appetite over the past 3 months. This is significant because chronic alcohol use can lead to malnutrition, gastrointestinal issues, and liver damage. Weight loss and poor appetite may indicate underlying conditions such as gastritis, pancreatitis, or liver disease, which require further evaluation and intervention.
Choice B: Smoking history
The client quit smoking over 20 years ago and has no current respiratory issues. While smoking history is important for a comprehensive health assessment, it does not require immediate follow-up in this context as it is not directly related to the current acute issues of alcohol intoxication and potential withdrawal.
Choice C: Blood alcohol level
The client’s blood alcohol level (BAC) is 310 mg/dL, which is significantly elevated (normal range: 0 to 50 mg/dL). This level of intoxication can lead to severe complications such as respiratory depression, aspiration, and even death. Immediate medical intervention is necessary to manage the acute effects of alcohol intoxication and to monitor for withdrawal symptoms.
Choice D: Client’s recent loss
The recent death of the client’s parents is a significant emotional stressor that has contributed to the relapse of alcohol use disorder. Addressing this loss is crucial for the client’s mental health and recovery process. The nurse should ensure that the client receives appropriate psychological support and counseling to cope with this loss1.
Choice E: Genitourinary assessment
The client reports no known genitourinary problems. Therefore, this area does not require immediate follow-up in the context of the current admission for alcohol use disorder.
Choice F: Client’s recent consumption of alcohol
The client had their last drink 2 hours ago. This information is critical for monitoring potential alcohol withdrawal symptoms, which can begin within a few hours after the last drink and can be life-threatening if not properly managed. Close monitoring and timely intervention are essential
Choice G: Neurological assessment
The client is intoxicated, has slurred speech, and is unable to coherently respond to questions. These neurological symptoms indicate significant alcohol intoxication and the potential for withdrawal symptoms. Continuous neurological assessment is necessary to monitor for any changes in mental status and to prevent complications.
Choice H: Cardiac assessment
The client has a normal sinus rhythm and palpable pulses with no history of heart disease. While cardiac assessment is always important, there are no immediate concerns in this context that require follow-up.
Choice I: Respiratory assessment
The client’s respiratory rate is 10/min, which is on the lower end of normal (normal range: 12-20/min). However, the client has clear lungs and no shortness of breath. While respiratory status should be monitored, it is not an immediate concern requiring follow-up in this context.

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A nurse is reviewing the day 5 vital signs and nurse’s notes. Exhibits A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing for an interprofessional meeting to discuss the plan of care for a client. Which of the following information should the nurse plan to communicate to a social worker?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","D","F","G"]

Explanation

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A nurse is reviewing the day 5 vital signs and nurse’s notes.

Exhibits

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.