Difficulty: Medium
Average Score: 85%
Simulated
Passage / Scenario
Medical History and Physical ExaminationNeurological: The client is intoxicated, has slurred speech, and is unable to respond coherently 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 the client states they quit smoking over 20 years ago.
Gastrointestinal: The client reports weight loss over the past 3 months and minimal appetite.
Genitourinary: The client reports no known problems.
Impression:
Relapse of alcohol use disorder.
Plan:
Admit for alcohol use disorder and observe for alcohol withdrawal.
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
Day 2, 0800:
Temperature: 37.3┬░C (99.1┬░F)
Blood pressure: 198/86 mm Hg
Heart rate: 116/min
Respiratory rate: 22/min
NurseÔÇÖs Notes
The client was brought in by a family member who states that the client has been drinking ÔÇÿnonstopÔÇÖ since the death of the clientÔÇÖs parents 3 months ago. The client has a history of alcohol use disorder for over 20 years. The client attended an inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died. According to the clientÔÇÖs family member, the client has been unable to cope with the sudden death of their parents. The client is currently unemployed after being laid off. The clientÔÇÖs family member states, ÔÇ£Everything combined caused the drinking to start again.ÔÇØ The family member estimates the clientÔÇÖs last drink was 2 hours ago. On Day 2 at 0800, the client is in the bathroom vomiting. The nurse assisted the client with oral and facial hygiene. The client states, ÔÇ£I feel awful.ÔÇØ The client is oriented, lethargic, and weak with visible hand shaking. The client reports they were up most of the night.
Diagnostic Results
Blood alcohol level (BAC): 310 mg/dL (0 to 50 mg/dL)
A nurse is caring for a client who is experiencing alcohol withdrawal.Exhibits A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, specify if the potential prescription is anticipated or contraindicated for the client.
Rationale
Correct Answer:
Rationale:
- Methadone is contraindicated as it may worsen the client's condition due to its potential for respiratory depression.
- Nutritional consult is anticipated to address potential malnutrition and vitamin deficiencies common in alcohol use disorder.
- Performing AUDIT is contraindicated as it may not be appropriate during acute alcohol withdrawal.
- Complete blood count and basic metabolic profile are anticipated to assess for any alcohol-related complications.
- Group therapy is anticipated to provide social support and coping skills.
- Schedule ECT is contraindicated as it is not indicated for alcohol withdrawal.
- Diazepam is anticipated to manage alcohol withdrawal symptoms.
Rationale:
- Methadone is contraindicated as it may worsen the client's condition due to its potential for respiratory depression.
- Nutritional consult is anticipated to address potential malnutrition and vitamin deficiencies common in alcohol use disorder.
- Performing AUDIT is contraindicated as it may not be appropriate during acute alcohol withdrawal.
- Complete blood count and basic metabolic profile are anticipated to assess for any alcohol-related complications.
- Group therapy is anticipated to provide social support and coping skills.
- Schedule ECT is contraindicated as it is not indicated for alcohol withdrawal.
- Diazepam is anticipated to manage alcohol withdrawal symptoms.