A medical surgical nurse is caring for a client admitted during the night from ER (emergency room) with a diagnosis of alcohol intoxication
The nurse has just admitted the client to the room and is unable to obtain much history due to the client?s lethargic state. Which of the following would be an appropriate action by the nurse? 1. Approach the client with caution when obtaining vital signs and shift assessments.
2. Place the client in a room farthest from the nurse?s station as not to disturb other clients.
3. Place the client in four-point restraints as a protective measure.
4. Perform neurovascular assessments every 2 hours to determine level of consciousness.
1
Explanation: 1. Alcohol withdrawal clients may lash out in violence. Placing the client farthest away from the
nurse?s station may cause added liability to the organization due to the client?s lethargic state
and potential for harm if not closely monitored. Placing the client in four-point restraints and
performing assessments every 2 hours may contribute to increased aggression by the client.
You might also like to view...
A prenatal client asks the nurse how the baby can possibly come out through her vagina, because a vagina is not nearly as big as a baby. What should the nurse include when answering this patient's question? The vagina:
1. Usually tears as it stretches during childbirth. 2. Is designed to allow a baby come through. 3. Changes from pregnancy hormones and stretches more. 4. Dilates and effaces in labor so the baby can get out.
A patient is diagnosed as having elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of:
A) Lipids and fibrous tissue B) WBCs C) Lipoproteins D) High-density cholesterol
A clinic patient was started on leflunomide. The nurse expects this medication will do which of the following:
1. Decrease joint movement at first 2. Cause the patient to feel flushed 3. Reduce symptoms and slow joint damage 4. Increase fluid in the joints
Which statement(s) regarding type 2 diabetes mellitus would be correct? (Select all that apply.)
a. Type 2 diabetes is more prevalent in overweight people older than 45 years. b. A genetic predisposition exists for the development of type 2 diabetes mellitus. c. Type 2 diabetes requires lifelong insulin replacement. d. Type 2 diabetes is often diagnosed after complications have resulted. e. Women have a higher incidence of type 2 diabetes.