Difficulty: Medium
Average Score: 80%
Simulated
A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)
Correct answer
A,BC,D,E
Rationale
The correct choices for priority risk assessment for a client with acute alcohol intoxication are A, B, C, D, and E.
A: Risk for aspiration is crucial due to impaired gag reflex, leading to the potential for choking on vomit.
B: Impaired coordination and judgment can result in accidents and injuries.
C: Alcohol toxicity can affect liver function, leading to complications.
D: Dizziness and unsteady gait increase the risk of falls and related injuries.
E: Alcohol impairs immune function, increasing the risk of infections.
Other choices are less immediate concerns or not directly related to the acute effects of alcohol intoxication, making them lower priority for assessment in this scenario.
A: Risk for aspiration is crucial due to impaired gag reflex, leading to the potential for choking on vomit.
B: Impaired coordination and judgment can result in accidents and injuries.
C: Alcohol toxicity can affect liver function, leading to complications.
D: Dizziness and unsteady gait increase the risk of falls and related injuries.
E: Alcohol impairs immune function, increasing the risk of infections.
Other choices are less immediate concerns or not directly related to the acute effects of alcohol intoxication, making them lower priority for assessment in this scenario.