Difficulty: Medium
Average Score: 64%
Simulated
Passage / Scenario
Nurses' NotesClient brought in by a family member who states that the client has been drinking "nonstop since the death of the client's parents 3 months ago."
Client has a history of alcohol use disorder for over 20 years.
Client attended inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.
According to the client's family member, the client has been unable to cope with the sudden death of their parents. Client is currently unemployed after being laid off.
Client's family member states, "Everything combined caused the drinking to start again." Family member estimates the client's last drink was 2 hr ago.
Vital Signs
Admission, 1600:
Temperature 36.1┬░ C (97┬░ F)
Blood pressure 98/66 mm Hg
Heart rate 76/min
Respiratory rate 10/min
Pulse oximetry 95% on room air
Diagnostic Results
Blood alcohol level (BAC) 310 mg/dL (0 to 50 mg/dL)
History & Physical
Neurological: Client is intoxicated, has slurred speech, and is unable to coherently respond to questions. Cardiovascular: Normal sinus rhythm and pulses palpable. No history of Heart disease.
Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders and client states they quit smoking over 20 years ago.
Gastrointestinal: Client reports weight loss over the past 3 months and minimal appetite. Genitourinary: Client reports no known problems.
Impression:
Relapse of alcohol use disorder. Plan:
Admit for alcohol use disorder and observe for alcohol withdrawal.
A nurse in a mental health facility is admitting a client.Exhibits:A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.
Correct answer
B,C,D,E,F
Rationale
Correct Answer: B, C, D, E, F
Rationale:
B: Client's recent consumption of alcohol should be followed up as it indicates potential relapse or withdrawal symptoms.
C: Blood alcohol level should be monitored to assess intoxication level or withdrawal risk.
D: Client's recent loss may trigger emotional distress or exacerbate alcohol use disorder symptoms.
E: Respiratory assessment is crucial due to potential respiratory depression associated with alcohol use.
F: Neurological assessment is needed to evaluate cognitive function and potential alcohol-related neurological impairment.
Summary:
A: Smoking history is not directly related to immediate alcohol use disorder management.
G: Cardiac assessment is not a priority unless there are specific cardiac symptoms present.
Rationale:
B: Client's recent consumption of alcohol should be followed up as it indicates potential relapse or withdrawal symptoms.
C: Blood alcohol level should be monitored to assess intoxication level or withdrawal risk.
D: Client's recent loss may trigger emotional distress or exacerbate alcohol use disorder symptoms.
E: Respiratory assessment is crucial due to potential respiratory depression associated with alcohol use.
F: Neurological assessment is needed to evaluate cognitive function and potential alcohol-related neurological impairment.
Summary:
A: Smoking history is not directly related to immediate alcohol use disorder management.
G: Cardiac assessment is not a priority unless there are specific cardiac symptoms present.