What is the most important factor for the nurse to assess when doing an admission assessment of a client with a history of alcoholism?
If the client has a history of addictive behaviors
Whether the client has had previous rehabilitation for alcoholism
Their previous and current coping skills
When the client last had a drink of alcohol
The Correct Answer is D
d. When the client last had a drink of alcohol
Explanation of Choices
Choice A Reason: If the Client Has a History of Addictive Behaviors
Assessing whether the client has a history of addictive behaviors is important as it provides insight into the client’s overall pattern of substance use and potential risk for relapse. However, while this information is valuable for developing a comprehensive treatment plan, it is not the most immediate concern during the initial admission assessment. The primary focus should be on identifying any immediate risks or needs, such as the potential for alcohol withdrawal.
Choice B Reason: Whether the Client Has Had Previous Rehabilitation for Alcoholism
Knowing whether the client has had previous rehabilitation for alcoholism can help the nurse understand the client’s treatment history and any previous interventions that may have been effective or ineffective. This information is useful for planning ongoing care and support. However, it is not the most critical factor to assess during the initial admission, as it does not directly address the client’s current physical and mental state.
Choice C Reason: Their Previous and Current Coping Skills
Evaluating the client’s previous and current coping skills is essential for understanding how they manage stress and triggers related to their alcoholism. This assessment can inform the development of personalized coping strategies and support mechanisms. Nonetheless, while important for long-term treatment planning, it is not the most urgent factor to assess during the initial admission.
Choice D Reason: When the Client Last Had a Drink of Alcohol
Determining when the client last had a drink of alcohol is the most important factor to assess during the initial admission. This information is crucial for predicting the onset of alcohol withdrawal symptoms, which can begin as early as 4 to 6 hours after the last drink. Early identification of potential withdrawal allows the healthcare team to implement appropriate monitoring and interventions to manage withdrawal symptoms and prevent complications. Alcohol withdrawal can be life-threatening if not properly managed, making this assessment a top priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Anchovies
Anchovies are a type of small, oily fish that are often used in various dishes for their strong flavor. They are rich in omega-3 fatty acids and other nutrients. However, there is no known interaction between anchovies and disulfiram. Disulfiram specifically interacts with alcohol and alcohol-containing products, causing unpleasant reactions. Therefore, anchovies are not a food item that needs to be avoided while taking disulfiram.
Choice B Reason: Spinach
Spinach is a leafy green vegetable that is high in vitamins, minerals, and antioxidants. It is generally considered a healthy food and does not have any known interactions with disulfiram. Patients taking disulfiram do not need to avoid spinach as it does not contain alcohol or any substances that would cause a reaction with the medication.
Choice C Reason: Grapefruit Juice
Grapefruit juice is known to interact with various medications by affecting the enzymes that metabolize these drugs in the liver. However, there is no specific interaction between grapefruit juice and disulfiram. While grapefruit juice can affect the metabolism of certain medications, it does not cause the same type of reaction that alcohol does when taken with disulfiram. Therefore, it is not necessary for patients on disulfiram to avoid grapefruit juice.
Choice D Reason: Alcoholic Beverages
Alcoholic beverages are the primary substance that must be avoided while taking disulfiram. Disulfiram works by inhibiting the enzyme acetaldehyde dehydrogenase, which is involved in metabolizing alcohol. When alcohol is consumed, acetaldehyde accumulates in the body, leading to unpleasant symptoms such as nausea, vomiting, headache, and flushing. This reaction is intended to deter individuals from drinking alcohol. Therefore, it is crucial for patients taking disulfiram to avoid all forms of alcohol, including alcoholic beverages, to prevent these adverse reactions.
Correct Answer is B
Explanation
Choice A Reason: Insert a nasogastric tube
This choice is incorrect. Inserting a nasogastric tube is not the highest priority intervention for a client who has just received naloxone. While it may be necessary in some cases for other reasons, the immediate concern after naloxone administration is to ensure the client’s airway is open and they are breathing adequately. Naloxone reverses opioid effects, which can cause respiratory depression, so monitoring the airway and vital signs is crucial.
Choice B Reason: Monitor airway and vital signs
This choice is correct. The highest priority after administering naloxone is to monitor the client’s airway and vital signs. Naloxone can rapidly reverse opioid-induced respiratory depression, but its effects may wear off before the opioids are completely metabolized, leading to a risk of re-sedation and respiratory depression. Continuous monitoring ensures that any changes in the client’s condition are detected and managed promptly.
Choice C Reason: Insert an indwelling urinary catheter or monitor output
This choice is incorrect. While monitoring urine output can be important in assessing overall kidney function and fluid balance, it is not the highest priority immediately after naloxone administration. The primary concern is the client’s respiratory status and ensuring they maintain an open airway and adequate ventilation.
Choice D Reason: Anticipate and treat hyperpyrexia with cooling measures
This choice is incorrect. Hyperpyrexia (extremely high fever) is not a common immediate concern following naloxone administration. The primary focus should be on the client’s respiratory status and vital signs. Treating hyperpyrexia would be important if it were present, but it is not typically associated with naloxone administration.
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