A 39-year-old male client is admitted to a detoxification unit for treatment of alcohol withdrawal. He has been on a binge and consumed nothing except beer for the past 2 weeks. He is estranged from his wife and children
Because of his alcohol use, he has also recently lost his job, which was the sole source of income for the family. His wife refuses to return home until he commits to sobriety. Which nursing diagnoses are relevant to this situation? Select all that apply.
A) Risk for injury related to central nervous system (CNS) agitation
B) Imbalanced nutrition related to inadequate intake
C) Dysfunctional family processes related to alcoholism
D) Ineffective role performance related to loss of job
E) Fluid volume excess related to binge drinking
A, B, C, D
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The nurse is assessing a sexually active heterosexual woman who does not use birth control. The nurse explains that the chance of becoming pregnant with each act of unprotected intercourse is what percentage?
A. 5-10% B. 10-15% C. 15-20% D. 20-25%
A community nurse assesses a client, who has an allergy to bees, after a bee sting. The client's lips are swollen, and wheezes are audible. What is the priority action of the nurse?
a. Elevate the site and notify the client's next of kin. b. Remove the stinger with tweezers and encourage rest. c. Administer diphenhydramine (Benadryl) and apply ice. d. Administer an EpiPen from the first aid kit and call 911.
When caring for a client with systemic lupus erythematosus the nurse should provide teaching that addresses:
A) the need to adhere to a high-protein diet. B) the need for daily aerobic exercises. C) skin care and limiting of sun exposure. D) the use of birth control to prevent pregnancy.
You hear an alert and oriented male resident make a sexual comment to a female resident. The female resident appears embarrassed and uncomfortable. What should you do?
a. Tell the male resident to behave. b. Nothing. It is none of your business. c. Tell the nurse at once. d. Call the male resident's family.