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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- A. Contact the laboratory to obtain a blood sample.
- B. Prepare the client for a CT scan.
- C. Check the client’s pupil reactivity.
- D. Obtain a urine specimen.
- E. Perform a developmental screening test.
Correct Answer: A, B, C, D
Rationale: The correct interventions for a client experiencing alcohol intoxication are A, B, C, and D. A blood sample is crucial to assess alcohol levels. A CT scan may be needed to rule out head trauma or other underlying issues. Checking pupil reactivity can indicate neurological status. Obtaining a urine specimen helps assess kidney function and possible drug use. Choice E, performing a developmental screening test, is not relevant to the immediate care needs of an individual with alcohol intoxication.
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A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. "The legal requirement for client confidentiality ceases if the client is deceased."
- B. "Staff members are required to divulge information to attorneys if they call for information."
- C. "Health care workers are not required to answer a court's requests for information about a client's disclosure."
- D. "Providers are required to warn individuals if the client threatens harm."
Correct Answer: D
Rationale: The correct answer is D because it refers to the duty to warn, which is a legal exception to client confidentiality. When a client poses a serious and imminent threat of harm to others, healthcare providers have a duty to warn those at risk. This exception prioritizes public safety over confidentiality.
Explanation of why other choices are incorrect:
A: Incorrect. Confidentiality typically extends even after a client's death to protect their privacy rights and maintain trust in healthcare providers.
B: Incorrect. Disclosing information to attorneys without client consent violates confidentiality unless required by law or court order.
C: Incorrect. Healthcare workers are generally required to comply with court requests for information unless protected by a legal privilege.
E, F, G: Not provided.
A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, “I don't know why my wife left me.” The client receives a diagnosis of anxiety. The nurse realizes the client’s findings support which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: The correct answer is D: Panic. The client is experiencing severe physical symptoms (chest pain, headache, shortness of breath) and is unable to identify the source of his distress, which indicates a high level of anxiety. Panic level is characterized by overwhelming fear and physical symptoms that can mimic a heart attack. Mild anxiety (A) is characterized by minor discomfort, moderate anxiety (B) involves increased heart rate and muscle tension, and severe anxiety (C) includes more pronounced physical symptoms. In this case, the client's presentation aligns most closely with panic level anxiety.
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing?
- A. Situational
- B. Maturational
- C. Adventitious
- D. Developmental
Correct Answer: A
Rationale: The correct answer is A: Situational crisis. This type of crisis occurs due to unexpected life events, such as the sudden death of a loved one, leading to feelings of overwhelm and inability to cope. In this case, the client's paralysis in handling work and family responsibilities aligns with the characteristics of a situational crisis. Other choices are incorrect because: B: Maturational crisis is related to normal life transitions, C: Adventitious crisis involves events like natural disasters, and D: Developmental crisis occurs during stages of life transition.
A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
Which intervention should a nurse prioritize when caring for a client with alcohol use disorder?
- A. Helping the client identify positive personality traits
- B. Providing adequate hydration and rest
- C. Confronting denial and defense mechanisms
- D. Educating the client about alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing adequate hydration and rest. This intervention is crucial because individuals with alcohol use disorder often experience dehydration and fatigue due to excessive alcohol consumption. Hydration helps to flush out toxins and restore electrolyte balance, while rest supports physical and mental recovery. Helping the client identify positive personality traits (A) may be beneficial in building self-esteem but is not as urgent as addressing physical needs. Confronting denial and defense mechanisms (C) may lead to resistance and hinder the therapeutic relationship. Educating the client about alcohol misuse (D) is important but should be done after addressing immediate physical needs.