Difficulty: Medium
Average Score: 80%
Simulated
What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?
Correct answer
B
Rationale
The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.