A nurse is reviewing the day 5 vital signs and nurse’s notes.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
While being oriented to person, place, and time is important, it does not necessarily indicate that the client is no longer a risk to themselves or others. Orientation alone does not ensure that the client can safely be without restraints.
Choice B reason:
Refusing medication unless released from restraints is a form of coercion and does not indicate that the client is safe to be without restraints. The decision to remove restraints should be based on the client's ability to follow commands and demonstrate safe behavior, not on their demands.
Choice C reason:
If a client states that they will harm themselves unless the restraints are removed, this indicates a high risk of self-harm. In such cases, restraints should not be removed until the client is assessed and deemed safe by a healthcare professional.
Choice D reason:
The ability to follow commands is a key indicator that the client can be safely managed without restraints. This demonstrates that the client is cooperative and can adhere to safety instructions, reducing the risk of harm to themselves or others.
Correct Answer is D
Explanation
Choice A reason:
Discussing relaxation techniques with the caregiver is a beneficial action that can help manage stress. However, it may not be the most immediate need for a caregiver who is in the midst of an emotional crisis. Relaxation techniques are more preventive and are best introduced when the caregiver is receptive and not overwhelmed by acute distress.
Choice B reason:
Referring the caregiver to a local support group is an excellent long-term strategy for providing support and resources. Support groups can offer a sense of community and shared experience, which is invaluable. Nonetheless, this action does not address the caregiver's immediate emotional needs and should follow after providing immediate emotional support.
Choice C reason:
Consulting social services to explore counseling options is an important step in supporting the caregiver's mental health. Counseling can provide professional assistance and coping strategies for the caregiver's stress and emotional burden. However, this is a step that should be taken after addressing the caregiver's immediate emotional distress.
Choice D reason:
Offering to talk with the caregiver about their feelings is the most immediate and direct way to provide support. It addresses the caregiver's current emotional state and provides an outlet for their feelings. Active listening and empathetic communication can help alleviate the caregiver's distress and serve as a bridge to further support and resources.
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