A nurse is reviewing the day 5 vital signs and nurses' 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.

Appetite

Movement through the stages of grief

Cognition

Participation in group therapy

Client resolves to limit alcohol consumption

Answer and Explanation

Correct Answer : A,B,D,E

A.   Appetite:
The client has a good appetite, which is a positive sign of progress. A healthy appetite can indicate the resolution of some symptoms related to alcohol withdrawal, as well as an improvement in the client’s general health and nutrition. It also suggests that the client is physically stabilizing and no longer experiencing significant nausea or gastrointestinal issues that are common in alcohol withdrawal.
B.   Movement through the stages of grief:
The client has accepted the news about their parents' death and is moving through the stages of grief.
This is a significant step in emotional healing and demonstrates psychological progress. Acceptance of
the loss is a positive indicator of the client’s ability to cope with the bereavement, which is important for
long-term recovery, particularly given that grief and emotional stress contributed to the relapse.
C.   Cognition:
While cognitive status is important, there is no direct evidence presented that the client's cognition is specifically improving in this case. The nurses' notes do not mention any cognitive deficits or assessments directly related to cognition, and there are no significant changes to indicate cognitive improvement. This would require further assessment to determine if cognitive function is indeed progressing.
D.   Participation in group therapy:
Participation in group therapy is another key indicator of progress. Group therapy is an essential part of recovery for clients with alcohol use disorder, providing a supportive environment where clients can share their experiences and receive feedback from others. The fact that the client is attending group therapy shows engagement in their treatment plan and is likely helping the client with social support and recovery-focused education.
E.   Client resolves to limit alcohol consumption:
The client has resolved to limit alcohol consumption, which is a clear and positive commitment to change. This suggests that the client is taking responsibility for their recovery and recognizes the need for behavioral change to prevent future alcohol use. Such a commitment is a crucial step in overcoming alcohol use disorder and achieving long-term sobriety.

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Correct Answer is ["B","C","D","E","F"]

Explanation

A. Smoking history: Although the client quit smoking over 20 years ago, there is no immediate concern with their smoking history in this admission. The focus is on the current alcohol-related issues, as smoking history does not have a direct, immediate impact on the client's current condition.
B. Client's recent consumption of alcohol: The client has a history of alcohol use disorder and has been drinking continuously since the death of their parents. Monitoring alcohol consumption and its effects is crucial for evaluating withdrawal symptoms and preventing complications like delirium tremens, which can occur in severe alcohol withdrawal.
C. Blood alcohol level: Since the client has consumed alcohol recently (within the past 2 hours), it is important to assess their blood alcohol level to determine the extent of intoxication and potential risks associated with alcohol withdrawal. This helps guide immediate management and interventions.
D. Client's recent loss: The death of the client's parents is a significant stressor that likely contributed to the relapse in alcohol use. This emotional distress should be addressed as part of the care plan, as it may be influencing the client's mental and emotional state, which can impact their recovery process.

E. Respiratory assessment: The client has a respiratory rate of 10/min, which is low and could be indicative of respiratory depression, especially if the client is intoxicated or if withdrawal symptoms are imminent. Monitoring respiratory status is important to ensure adequate oxygenation and detect early signs of respiratory distress.
F. Neurological assessment: The client is intoxicated and exhibiting slurred speech, which suggests neurological impairment. It is important to monitor the client's neurological status for any signs of complications such as confusion, altered consciousness, or the onset of alcohol withdrawal seizures or delirium.
G. Cardiac assessment: The client has a normal heart rate and rhythm upon initial assessment, and there is no indication of cardiovascular distress. While cardiovascular monitoring is important, the client's current condition does not show any immediate signs that require further follow-up.
H. Gastrointestinal assessment: Although the client reports weight loss and a minimal appetite, these findings are likely related to their alcohol use disorder and could be addressed as part of the ongoing management of the condition. However, this does not require immediate follow-up compared to the more urgent issues related to intoxication and withdrawal.
I. Genitourinary assessment: The client reports no known problems, and there are no immediate concerns about their genitourinary system. This assessment is less of a priority at this time compared to monitoring for alcohol-related issues.

A. Generalizing B. Manipulating C. Distracting D. Placating

Correct Answer is A

Explanation

A. This statement is an example of generalizing, where the client makes a broad statement without recognizing specific instances or nuances. "Always criticizing" is an overgeneralization and may not accurately reflect the situation.
B. Manipulating involves influencing or controlling others in an indirect or deceptive way. The statement does not suggest manipulation but rather a complaint about perceived behavior.
C. Distracting communication occurs when someone diverts attention away from the topic. The statement does not exhibit this behavior; it is a direct expression of concern.
D. Placating involves trying to calm someone down or please them to avoid conflict. The client's statement is more accusatory than an attempt to placate.

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Body system	Findings
Neurological	Impaired cognition Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Tremulousness Malaise

A nurse is reviewing the day 5 vital signs and nurses' 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 in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is assessing a client's communication patterns. The client states, "My partner is always criticizing me." This statement is an example of which of the following types of dysfunctional communication?

Correct Answer is A

Explanation

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A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

A nurse is reviewing the day 5 vital signs and nurses' 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.