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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A: Obtain a capillary glucose level. This is the first action that the nurse should do, as it can diagnose hypoglycemia, which is a low blood sugar level that can cause jitteriness and tachypnea in newborns. Hypoglycemia can be caused by maternal diabetes, prematurity, infection, or delayed feeding. The nurse should check the glucose level using a heel stick and a glucometer.

Choice B: Feed 30 mL of 10% dextrose in water. This is not the first action that the nurse should do, as it may not be appropriate for all newborns with jitteriness and tachypnea. Feeding 10% dextrose in water can raise the blood sugar level, but it may also cause rebound hypoglycemia or fluid overload. The nurse should feed only after confirming hypoglycemia and obtaining a healthcare provider's order.

Choice C: Wrap tightly in a blanket. This is not the first action that the nurse should do, as it may not address the underlying cause of jitteriness and tachypnea in newborns. Wrapping tightly in a blanket can prevent heat loss and conserve energy, but it may also impair breathing or circulation. The nurse should wrap only after ruling out other causes of jitteriness and tachypnea.

Choice D: Encourage the mother to breastfeed. This is not the first action that the nurse should do, as it may not be feasible or effective for all newborns with jitteriness and tachypnea. Breastfeeding can provide nutrition and bonding for newborns, but it may also be difficult or contraindicated for some newborns with respiratory distress or infection. The nurse should encourage breastfeeding only after assessing and stabilizing the newborn's condition.

Correct Answer is ["31.6"]

Explanation

The correct answer is : 31.6 mL

Let’s calculate this step by step:

Step 1: Convert 10 mg of teriparatide to mcg. We know that 1 mg = 1000 mcg. So, 10 mg = 10 × 1000 mcg = 10000 mcg.

Step 2: The medication is labeled as 760 mcg/2.4 ml. This means that 760 mcg of the medication is present in 2.4 mL.

Step 3: Now, we need to find out how many ml will contain 10000 mcg of the medication. We can set up a proportion to solve this:

(760 mcg / 2.4 ml) = (10000 mcg / x mL)

Step 4: Solving for x, we cross-multiply and divide:

x ml = (10000 mcg × 2.4 ml) ÷ 760 mcg

Step 5: Calculate the result:

x ml = 24000 mcg·ml ÷ 760 mcg = 31.57894736842105 mL

Step 6: If rounding is required, round to the nearest tenth:

x ml = 31.6 mL

So, the nurse should administer 31.6 mLof the medication.

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Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Correct Answer is A

Explanation

The nurse is preparing a dose of 10 mg of teriparatide. The medication is labeled 760 mcg/2.4 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["31.6"]

Explanation

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