The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:
orient to reality.
identify social supports.
replace fluids.
apply restraints.
The Correct Answer is C
C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.
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Related Questions
Correct Answer is B
Explanation
B. It's essential for the client to receive accurate information about their safety, efficacy, and potential interactions with other medications. Health food store employees may not always have the necessary expertise to provide comprehensive information on these aspects.
A. Yoga can indeed improve flexibility and balance, which can be beneficial for individuals with osteoarthritis. Therefore, this choice does not indicate a need for client teaching.
C. Glucosamine helps with pain control and bone remodeling to improve overall functionality.
D. Prayer and spirituality can provide emotional support and improve overall well-being, they may not directly address the underlying physical symptoms of osteoarthritis. This may indicate a need for client teaching, as it may reflect the client's personal beliefs and coping strategies.
Correct Answer is B
Explanation
B. Airborne precautions are used for diseases that can be transmitted through tiny respiratory droplets that remain in the air for extended periods. Examples include tuberculosis and measles. Given the symptom of coughing up blood and the possibility of an infectious respiratory disease, initiating airborne precautions could be warranted.
A. Droplet precautions are typically implemented for diseases that spread through respiratory droplets, such as influenza or pertussis. However, coughing up blood suggests a more serious condition that may not be adequately addressed by droplet precautions alone.
C. Positive pressure rooms are typically used in healthcare settings to prevent outside air from entering the room, thus reducing the risk of airborne contaminants. While this measure can be beneficial for certain conditions, such as those requiring airborne precautions, it may not be the priority intervention.
D. Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). While this precaution is important for protecting immunocompromised patients from infections, it may not be the priority intervention.
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