Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?
Maintain a quiet, non-stimulating environment.
Force oral fluids and provide frequent small meals.
Confront the client's denial of substance abuse.
Encourage attendance and group participation.
The Correct Answer is A
Choice B reason: Forcing oral fluids and providing frequent small meals are not the most important interventions for a client with alcohol withdrawal delirium. Although hydration and nutrition are important to prevent dehydration and electrolyte imbalance, they are not the priority in this case. The client may have difficulty swallowing, vomiting, or aspiration due to altered mental status.
Choice C reason: Confronting the client's denial of substance abuse is not an appropriate intervention for a client with alcohol withdrawal delirium. The client may not be able to comprehend or respond rationally to such confrontation due to impaired cognition and perception. The nurse should avoid arguing or challenging the client's beliefs and focus on providing safety and comfort.
Choice D reason: Encouraging attendance and group participation is not a feasible intervention for a client with alcohol withdrawal delirium. The client may not be able to participate in any social or educational activities due to severe withdrawal symptoms and delusions. The nurse should limit visitors and stimuli and provide one-to-one supervision and reassurance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.
Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.
Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.
Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.
Correct Answer is C
Explanation
Choice A: An adolescent with multiple contusions due to a fall that occurred 2 days ago is not a client that the charge nurse should assign to the RN, as this is a stable and low-acuity client who can be safely cared for by the PN. This is a distractor choice.
Choice B: A 75-year-old client with renal calculi who requires urine straining is not a client that the charge nurse should assign to the RN, as this is a routine and non-complex task that can be performed by the PN. This is another distractor choice.
Choice C: A 30-year-old depressed client who admits to suicide ideation is a client that the charge nurse should assign to the RN, as this is an unstable and high-risk client who requires close monitoring, assessment, and intervention by the RN. Therefore, this is the correct choice.
Choice D: A 64-year-old client who had a total hip replacement the previous day is not a client that the charge nurse should assign to the RN, as this is a postoperative and moderate-acuity client who can be managed by the PN under the supervision of the RN. This is another distractor choice.
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