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 C

Explanation

A. Auscultate for bowel sounds in all quadrants: While assessing bowel sounds can help evaluate gastrointestinal function, it does not assess the effectiveness of a proton pump inhibitor. PPIs primarily work to reduce gastric acid secretion, not to change bowel sounds.

B. Measure the client's fluid intake and output: Measuring fluid intake and output is important for general fluid balance but does not specifically assess the effectiveness of a PPI. This action is more relevant to other concerns such as hydration status.

C. Ask the client about gastrointestinal pain: The primary indication for PPIs is the treatment of gastrointestinal conditions like acid reflux, ulcers, or GERD. Asking the client about gastrointestinal pain directly assesses the effectiveness of the PPI in reducing symptoms such as heartburn or discomfort.

D. Monitor the client's serum electrolyte levels: While electrolyte imbalances can be a concern with prolonged PPI use, monitoring electrolytes is not the immediate method to assess PPI effectiveness. Reduction in gastrointestinal symptoms is a more direct indicator.

A. Client exhibits a frequent productive cough. B. Client reports using the incentive spirometer every hour while awake. C. Client's breath sounds are clear to auscultation bilaterally. D. Client demonstrates proper use of an incentive spirometer.

Correct Answer is C

Explanation

A. Client exhibits a frequent productive cough: While a productive cough may indicate airway clearance, it does not assess the effectiveness of the incentive spirometer. The primary goal of the incentive spirometer is to improve lung expansion, not to stimulate coughing.

B. Client reports using the incentive spirometer every hour while awake: Regular use of the incentive spirometer is important, but it alone does not fully evaluate its effectiveness. The goal is to improve lung function, and a physical assessment is needed to gauge this.

C. Client's breath sounds are clear to auscultation bilaterally: This is the best indicator of the effectiveness of the incentive spirometer. Clear breath sounds suggest improved lung expansion and ventilation, which is the primary goal of using the device.

D. Client demonstrates proper use of an incentive spirometer: While proper technique is essential for effectiveness, demonstrating correct use does not fully assess whether the desired outcomes are achieved.

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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

Naxlex Comprehensive Predictor Exams

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Correct Answer is C

Explanation

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is C

Explanation

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