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 B
Explanation
Choice A Reason:
Promoting activities that encourage self-reflection. While promoting self-reflection is important in the therapeutic process, it is not the most essential aspect initially for establishing a trusting nurse-patient relationship. Self-reflection activities are more effective once a foundation of trust has been established.
Choice B Reason:
Conveying an accepting attitude. This statement is correct. Conveying an accepting attitude is crucial in the initial stages of establishing a trusting nurse-patient relationship. Patients with borderline personality disorder often feel judged and misunderstood. An accepting attitude helps to create a safe and supportive environment, which is essential for building trust and encouraging open communication.
Choice C Reason:
Identifying community resources. Identifying community resources is important for long-term support and management of borderline personality disorder, but it is not the most essential aspect initially for establishing trust. This step is more relevant once the therapeutic relationship has been established and the patient is ready to engage with external support systems.
Choice D Reason:
Providing positive feedback. Providing positive feedback is beneficial in reinforcing positive behaviors and encouraging progress. However, it is not the most essential aspect initially for establishing trust. Positive feedback is more effective when the patient already feels understood and supported by the nurse.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
“I’d rather be dead than living like this. I do not want to be alive.”
This statement reflects a common symptom of major depressive disorder, which is suicidal ideation. Individuals with major depressive disorder often experience feelings of hopelessness and worthlessness, leading them to believe that life is not worth living. This statement is a clear indication of the severity of the individual’s depressive symptoms and the need for immediate intervention to ensure their safety.
Choice B Reason:
“If I can just keep ignoring feelings.”
This statement is less likely to be heard from a client with major depressive disorder. Ignoring feelings is a coping mechanism that some individuals might use, but it does not directly reflect the core symptoms of major depressive disorder, which include persistent sadness, loss of interest in activities, and significant impairment in daily functioning. Therefore, this choice is not as indicative of major depressive disorder as the other statements.
Choice C Reason:
“I deserve to be this way. I’ve not accomplished anything important in my life.”
This statement reflects feelings of guilt and worthlessness, which are common symptoms of major depressive disorder. Individuals with this disorder often have a negative self-view and believe that they are failures or that they deserve to suffer. This statement highlights the individual’s low self-esteem and the pervasive negative thoughts that characterize major depressive disorder.
Choice D Reason:
“This is a bad episode, but I will be well soon.”
This statement reflects a more optimistic outlook, which is less common in individuals with major depressive disorder. However, it can still be heard from some clients who experience episodic depression and have hope for recovery. This statement indicates that the individual recognizes their current state as temporary and believes in the possibility of improvement, which can be a positive sign in the context of treatment.
Choice E Reason:
“I am determined to fight this episode and get through it.”
This statement reflects a proactive and positive attitude towards managing depression, which is less characteristic of major depressive disorder. While determination and resilience are important for recovery, individuals with major depressive disorder often struggle with motivation and energy, making it difficult for them to adopt such a mindset. Therefore, this choice is less likely to be heard from a client with major depressive disorder.
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