A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

The correct answers are choices B and D: "Offer ideas for ways to distract or redirect the client." and "Educate the spouse about the availability of adult care as a respite."

Choice A rationale:

Suggesting a long-term care facility should not be the first action. Early-stage Alzheimer's clients can often remain at home with proper support, and suggesting institutionalization might not be appropriate at this stage.

Choice B rationale:

This is a correct choice. Engaging the client with Alzheimer's in activities that distract or redirect their focus can be helpful. This approach can alleviate the spouse's concerns and provide some relief from exhaustion.

Choice C rationale:

While discussing dementia care options with the spouse is important, it might not directly address the spouse's current exhaustion and feelings of helplessness.

Choice D rationale:

This is a correct choice. Educating the spouse about adult care options for respite can provide much-needed breaks for the caregiver. Caring for someone with Alzheimer's can be emotionally and physically draining, so respite care can offer temporary relief.

Choice E rationale:

Suggesting anti-anxiety drugs for the spouse is not the best first action. While addressing caregiver stress is important, suggesting medication should come after considering other supportive measures.

The correct answer is choice C.

Choice A rationale:

Planning a therapeutic diet is important for overall client care, but it might not be the first priority. The client's significant weight loss and distorted body image require more immediate attention to address potential underlying mental health concerns..

Choice B rationale:

Providing a structured environment is beneficial, but it might not be the first priority in this situation. The client's distorted perception of weight and significant weight loss necessitate more immediate assessment and intervention.

Choice C rationale:

Assessing the client's nutritional status is the first priority in this scenario. The client's weight loss of 11 kg (25 lb) over 3 months and belief that she is fat are indicators of a possible eating disorder. Nutritional assessment helps determine the severity of the issue and guides appropriate interventions.

Choice D rationale:

While requesting a mental health consult is important, it is not the first priority. Addressing the client's immediate physical health, which includes assessing her nutritional status and potential risk for complications related to her distorted body image, takes precedence.