The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?
Administer thiamine intramuscular (IM)
Assist the client with personal hygiene needs
Place the client on continuous observation
Explain milieu therapy
The Correct Answer is B
A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.
B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.
C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.
D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "He may begin to try to cover recognition of his memory loss by creating events." As
dementia progresses, individuals may experience confabulation, which involves creating false memories to compensate for memory loss. This is a common symptom seen in the middle stages of dementia.
B. "He may have difficulty in a motor skill such as walking." While motor skills may be affected in the later stages of dementia, it is not typically one of the early signs.
C. "The inability to communicate with speech comes immediately after the early signs." This statement is not accurate. Communication difficulties may occur in later stages, but it is not an immediate progression from early signs.
D. "He may not recognize you and other people who have been in his life." This symptom, known as agnosia, may occur in later stages of dementia, but it is not one of the early signs.
Correct Answer is D
Explanation
A) Incorrect. Reverse isolation is not indicated in this situation. The client's symptoms are likely due to a side effect of the medication, not an infectious process.
B) Incorrect. While it may be necessary to withhold the next dose of medication, the client's symptoms require more immediate attention.
C) Incorrect. The client's symptoms are indicative of a serious adverse reaction, and dietary changes would not address the issue.
D) Correct. The client's symptoms, including severe muscle stiffness, difficulty swallowing, drooling, diaphoresis, and elevated vital signs, are indicative of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like risperidone.
The nurse should notify the healthcare provider immediately for further guidance and intervention.
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