What should be the priority nursing diagnosis for a client ...

[lunatika]

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
 
  A. Risk for injury R/T central nervous system stimulation
  B. Disturbed thought processes R/T tactile hallucinations
  C. Ineffective coping R/T powerlessness over alcohol use
  D. Ineffective denial R/T continued alcohol use despite negative consequences

Question 2

The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which of the following interventions should the nurse implement first?
 
  A) Administer an antianxiety drug such as lorazepam (Ativan) at these times.
  B) Explain the unit routine and the reasons for increased activity to the client.
  C) Keep unit activity to a minimum.
  D) Move the client to a quieter area during these times.

[johnpizzaz]

Answer to Question 1

A
The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

Answer to Question 2

D
Feedback: The nurse must alter the environment because the client will not learn new coping skills for frustrating or overly stimulating situations. Administering an antianxiety agent or explaining the routine of the unit and reasons for increased activity to the client may be done, but they are not the best initial intervention. The unit activity does not need to be kept at a minimum.