The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Dilated pupils, tachycardia, elevated blood pressure, elation.

Excessive eating, constipation, headache.

Nausea, vomiting, diaphoresis, anxiety, tremors.

Mood lability, poor hand coordination, fever, drowsiness.

Answer and Explanation

The Correct Answer is C

A. Dilated pupils, tachycardia, elevated blood pressure, elation: These symptoms are more typical of stimulant intoxication and do not indicate alcohol withdrawal. They are not consistent with the need for a detox protocol focused on alcohol or other depressants.

B. Excessive eating, constipation, headache: These symptoms are not associated with alcohol or drug intoxication or withdrawal. They do not suggest a need for detoxification medication protocols.

C. Nausea, vomiting, diaphoresis, anxiety, tremors: These are classic signs of alcohol withdrawal and suggest the need for detoxification. These symptoms require immediate intervention to manage withdrawal safely and avoid complications.

D. Mood lability, poor hand coordination, fever, drowsiness: These signs are more indicative of intoxication with substances like sedatives. While concerning, they do not point to alcohol withdrawal, which requires specific detox protocols.

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Correct Answer is B

Explanation

A. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting:While antiemetics can be helpful, this action may not address the underlying issue of food smells causing nausea. It is important to address the client’s sensory triggers.

B. Encourage family members to cook meals outdoors and bring the cooked food inside:
This can help reduce the trigger for nausea caused by the smell of cooking food. Cooking outdoors minimizes exposure to food smells, which could alleviate the client’s discomfort.

C. Assess the client's mucous membranes and report the findings to the healthcare provider: Assessing the mucous membranes is important in general care, especially for clients with cancer, but it is not directly related to the reported issue of nausea triggered by food smells.

D. Advise the client to replace cooked foods with a variety of different nutritional supplements: While nutritional supplements can be useful if the client is unable to tolerate solid foods, this advice doesn't address the root cause of the nausea related to food smells.

A. "Only your son can decide to who the laboratory results can be shared with." B. "I can give you those results as soon as I get them back from the laboratory." C. "I need to wait for the results of other tests before I can share the information to you." D. "Let us wait for the healthcare provider to come and share this information with you."

Correct Answer is A

Explanation

A. "Only your son can decide to who the laboratory results can be shared with."
Since the client is 18 years old, he is legally an adult and has the right to confidentiality regarding his medical information. The nurse should inform the mother that the son must provide consent before sharing any test results with her.

B. "I can give you those results as soon as I get them back from the laboratory." The nurse cannot release the results to the mother without the client's consent, as he is an adult and his medical information is confidential.

C. "I need to wait for the results of other tests before I can share the information to you." The nurse’s ability to share the results with the mother is based on the client’s consent, not on waiting for other tests.

D. "Let us wait for the healthcare provider to come and share this information with you." While it may be helpful for the healthcare provider to discuss the results, the key issue here is the client's consent. The nurse should clarify that the client is the one who must authorize sharing the results.

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The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Nursing Test Bank

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