Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan for the client who is in withdrawal must include which nursing interventions?
Seizure precautions and vital signs.
Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered.
Suicide precautions because suicide atempts are frequent during withdrawal.
Vital signs and medications as prescribed.
The Correct Answer is B
Choice A reason: Seizure precautions and monitoring vital signs are important but not comprehensive enough for a complete care plan.
Choice B reason: This is the correct choice. It encompasses a broad range of interventions that are critical for a client undergoing alcohol withdrawal, including monitoring for various symptoms, ensuring safety, and administering medications.
Choice C reason: While suicide precautions are important, they are not the only intervention needed for a client in alcohol withdrawal.
Choice D reason: Monitoring vital signs and administering medications are important but do not cover all necessary precautions such as seizure and fall precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. The client's belief that "They're out to get me" is indicative of paranoia, a common symptom in schizophrenia.
Choice B reason: This choice is incorrect. Stilted language refers to an unnatural, formal way of speaking, not suspicion or guardedness.
Choice C reason: This choice is incorrect. Pressured speech is rapid and urgent speech, which is not described in the scenario.
Choice D reason: This choice is incorrect. Autistic thinking is associated with autism, not schizophrenia, and does not involve paranoia.
Correct Answer is B
Explanation
Choice A reason: While it's important to provide support, simply telling the client they have nothing to be ashamed of does not address the underlying issues or feelings the client may be experiencing.
Choice B reason: This response opens a dialogue and allows the client to share their experiences and challenges since the last admission, fostering a therapeutic relationship and understanding.
Choice C reason: This statement could be perceived as judgmental and may make the client feel worse, potentially hindering the therapeutic relationship.
Choice D reason: Asking why they started drinking again could come across as accusatory and may cause the client to become defensive or feel guilty, which is not conducive to recovery.
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