HESI CASE STUDY ALCOHOLISM

Which question should the nurse ask the client in order to determine whether the client is able to return to a precrisis level of functioning? "Do you have a support system and people who can help you?" "How have you successfully handled past crises?" "Why do you always feel so sad?" "What are some of your strengths?" Submit The

"Do you have a support system and people who can help you?" The nurse must determine if the client has an adequate support system.

Which routine admission prescriptions should the nurse question? A regular diet. Vital signs every 4 hours. Acetaminophen as needed. Urinalysis and urine drug screen. Submit

Acetaminophen as needed. The client is suspected of having liver problems due to alcohol. Acetaminophen can be toxic to the liver, especially in combination with alcohol. The nurse should question this prescription as it is contraindicated for the client.

Which interventions should the nurse implement? (Select all that apply.) Select all that apply Ask the primary HCP if the client can receive a prescription for chlordiazepoxide. Administer lorazepam 2 mg PO. Reassess vital signs in 2 hours. Place the client on a continuous pulse oximetry monitor. Provide an antiemetic.

Administer lorazepam 2 mg PO. The client has compromised liver function; therefore, a short-acting benzodiazepine such as lorazepam is best to give for withdrawal because it does not have active metabolites that can affect a diseased liver. Lorazepam is often given if a client has known liver disease or decreased liver function. Reassess vital signs in 2 hours. The nurse can reassess the vital signs to monitor for changes. Provide an antiemetic. The client reports feeling nauseous, so administering an antiemetic is advised.

Which response by the nurse is accurate? Disulfiram decreases cravings for alcohol. Disulfiram inhibits absorption of alcohol. Disulfiram blocks the effects of endorphins. Disulfiram prevents the client from drinking.

Disulfiram inhibits absorption of alcohol. Disulfiram inhibits the absorption of alcohol and raises the level of acetaldehyde, causing a severe reaction when alcohol is ingested.

Which action should the nurse take? Document that the initial client teaching was completed by the UAP. Praise the UAP for taking the initiative to complete higher priority tasks. Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse. Request that the UAP be assigned to another unit.

Explain to the UAP, away from the client, that initial client teaching must be performed by the nurse. Initial client teaching requires the expertise of the nurse.

What action should the nurse take next? Prepare the client for possible alcohol withdrawal. Further assess the client's drinking behaviors. Obtain blood alcohol content with a breathalyzer. Obtain a urine drug screen for polysubstance use.

Further assess the client's drinking behaviors. The CAGE questionnaire is only a screening tool used to identify alcohol abuse; therefore, further assessment is needed to make a diagnosis of alcoholism.

What is the first question that the nurse should ask? "Have people annoyed you by criticizing your drinking?" Have you ever felt bad or guilty about your drinking?" Have you ever thought that you should cut down on your drinking?" "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?"

Have you ever thought that you should cut down on your drinking?" This is the first question in the questionnaire. In CAGE, C stands for cut down. Alcoholic may realize they consume too much alcohol, which leads to uninhibited and embarrassing behavior. When sober, an alcoholic may make a pledge to reduce consumption.

Which products are acceptable for the client to use? (Select all that apply.) Select all that apply Ibuprofen. Mouthwash. Hand sanitizer. Petroleum jelly. Nonalcoholic beer.

Ibuprofen. Ibuprofen is a nonsteroidal antiinflammatory medication used to treat fever and mild to severe pain. It does not contain alcohol and is safe for the client to use. Petroleum jelly. Petroleum jelly does not contain alcohol, so it is safe for the client to use.

Which lab results indicate to the nurse the client likely has liver disease? Hyperkalemia. Increased aspartate aminotransferase (AST). Reduced alkaline phosphatase. Decreased blood urea nitrogen (BUN). Submit

Increased aspartate aminotransferase (AST). Liver disease can cause a change in tissues of the liver and result in an elevation of AST. The amount of AST in the blood is directly related to the number of damaged cells.

What mechanism of action accounts for symptoms of alcohol withdrawal delirium? Increased dopamine. Increased GABA. Decreased norepinephrine. Increased serotonin. Eight

Increased dopamine. Alcohol intake represses gamma-aminobutyric acid (GABA), which inhibits dopamine. When alcohol is eliminated, dopamine rebounds above the normal level, resulting in excitation and alterations in thought, perception, and orientation.

Which nursing intervention is most important to implement before disulfiram therapy? Obtain the client's written consent to comply with facility protocol. Ensure that the client will not have access to alcohol after discharge from the hospital. Determine the longest period of sobriety and need for abstinence. Help the client identify triggers leading to possible alcohol abuse.

Obtain the client's written consent to comply with facility protocol. Informed consent must be obtained to receive disulfiram therapy, or documentation can be noted in the chart that education was given about potential serious complications that can occur if client does not abstain from drinking.

Which goal is most important for alcohol detoxification? Discontinued drug-seeking behaviors. Physiological stabilization. Normal liver function test results. Enhanced coping skills.

Physiological stabilization. The acute management goals of alcohol detoxification begin with stabilizing the client physically and maintaining normal vital signs.

What is the therapeutic action of benzodiazepines? Potentiate the effects of GABA. Block the reuptake of dopamine. Block the reuptake of serotonin. Activate opioid receptors.

Potentiate the effects of GABA. Benzodiazepines potentiate the effects of GABA, which has a calming effect.

What is the rationale for giving thiamine (B1) and a multivitamin? Reduce the risk of Wernicke disease. Prevent occurrence of delirium tremens. Lessen alcohol withdrawal symptoms. Help increase the client's appetite.

Reduce the risk of Wernicke disease. Vitamin B deficiency is common in clients diagnosed with alcoholism. The small intestine is a major site of alcohol absorption, which interferes with adequate thiamine and all B vitamin absorption. Vitamin B deficiency can cause Wernicke disease.

Which is the most important consideration for discharge planning? Resources available to the client after discharge. Client's knowledge of the ongoing disease process. Longest period of sobriety and potential for relapse. Participation with Alcoholics Anonymous (AA) for abstinence.

Resources available to the client after discharge. The most important consideration is the availability of resources to the client after discharge. These resources can include counseling with significant others, group therapy, and self-help programs like Alcoholics Anonymous.

Which priority nursing problem should be addressed within 72 hours of admission? (Select all that apply.) Select all that apply Ineffective denial. Risk for injury. Ineffective coping. Altered nutrition. Risk for withdrawal.

Risk for injury. Risk for injury related to the client's thoughts of wanting to jump off a bridge is a priority nursing problem and the rationale for admission to the crisis unit. Altered nutrition. A client with alcohol dependency drinks alcohol instead of eating nourishing food, causing malabsorption of essential vitamins. Deficiency and malabsorption of vitamin B can cause Wernicke's disease, a severe problem with decreased cognitive functioning. Risk for withdrawal. Alcohol withdrawal can occur as early as 4 to 6 hours after the client's last drink.

What are the ramifications of drinking alcohol while taking disulfiram? (Select all that apply.) Select all that apply Severe headache. Nausea and vomiting. Hypertension. Chest pain. Hypotension.

Severe headache. A severe headache is one of the unpleasant consequences of drinking alcohol while taking Nausea and vomiting. Nausea and vomiting are unpleasant consequences of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Chest pain. Chest pain is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor. Hypotension. Hypotension is an unpleasant consequence of drinking alcohol while taking disulfiram, an aldehyde dehydrogenase inhibitor.

Which items can the nurse allow the client to keep in the room? (Select all that apply.) Select all that apply Tennis shoes without laces. Aftershave lotion. Electronic book reader. An electronic cigarette. A personal photo.

Tennis shoes without laces. Tennis shoes without laces do not typically pose a threat. Electronic book reader. The client may keep an electronic book reader, but it cannot connect to the internet. The client must keep the battery's charging cord at the nurse's desk and the staff will charge the battery when needed. A personal photo. Personal photos do not pose a threat and may help the client feel more comfortable in the environment.

Which behaviors of the client's partner exhibit codependency toward the client? (Select all that apply.) Select all that apply The client's partner states that moving out of their home caused the client to start drinking heavily. The client's partner removed hidden alcohol from the home and is now moving back to keep a close eye on the client. The client's partner brings two new pairs of jeans because the client only had one pair. The client's partner states they would like to have a child together. The client's partner paid all of the bills for the next two months so that the client won't have to worry about finances when discharged.

The client's partner states that moving out of their home caused the client to start drinking heavily. Finding excuses for alcohol abuse is considered codependent behavior. The client's partner removed hidden alcohol from the home and is now moving back to keep a close eye on the client. The client's partner feels responsible for the client. Searching for and removing alcohol from the home is further evidence of codependent behavior. The client's partner paid all of the bills for the next two months so that the client won't have to worry about finances when discharged. This shows that the client's partner feels a need to control the finances and assume responsibility for the client's duties.

If it is determined the client is dependent on alcohol, which information should the nurse obtain in order to predict the onset of withdrawal symptoms? The frequency with which the client drinks alcohol. The last time the client consumed an alcoholic beverage. The quantity of alcohol the client usually drinks. Past withdrawal symptoms the client has experienced.

The last time the client consumed an alcoholic beverage. This can help the nurse predict the onset of withdrawal symptoms, which can begin as early as 6 to 8 hours after alcohol use.

Who should the nurse ask to complete the adverse event report? The nurse should complete the full report. The client should complete as much of the form as he is able. The technician helping at the time of the accident needs to complete the report. The nurse and the HCP should write the account of the incident for the report.

The technician helping at the time of the accident needs to complete the report. The nurse should ask the technician to complete the report because the technician witnessed the client's fall.

Which data supports the need for admission to the hospital? Drinking alcohol and potential withdrawal. Ineffective denial about severity of problem. Elevated vital signs and liver disease. Thoughts of wanting to jump off a bridge.

Thoughts of wanting to jump off a bridge. The client is at risk for self-harm, which is a priority problem that requires hospitalization.

Which should the nurse anticipate if the client experiences symptoms of early withdrawal from alcohol? Mild disorientation and confusion. Tactile or auditory hallucinations. Tremors, nausea, and vomiting. Sleeping more than usual.

Tremors, nausea, and vomiting. In addition to tremors, nausea, and vomiting, other symptoms of early withdrawal include elevated vital signs, diaphoresis, insomnia, combativeness, agitation, and decreased concentration.

Which assessment is most important for safe alcohol detoxification? Vital signs at least every 4 hours. Type of alcohol ingested. Amount and last use of alcohol. History of delirium tremens (DTs).

Vital signs at least every 4 hours. Vital signs are an objective measure of alcohol withdrawal, especially when the diastolic blood pressure, pulse, and temperature are near or above 100.

When should the nurse begin assessing for withdrawal? Within 8 to 12 hours of the client's last drink. 12 hours after admission. As blood pressure becomes elevated. When hand tremors are visible.

Within 8 to 12 hours of the client's last drink. Early alcohol withdrawal can begin as early as 4 to 6 hours after substance use is stopped.