Chapter 6

Alcohol Withdrawal Case Study

Answers

1. Correct answer: C The MOST important assessment finding to validate is C) Mild confusion and agitation. While options A, B, and D are relevant to Mr. Nguyen’s condition, they are not as critical as assessing his mental status. Mr. Nguyen’s history of alcohol dependence puts him at risk for alcohol withdrawal delirium, which can be life-threatening. The other options are expected findings given his diagnosis of acute pancreatitis and history of alcohol withdrawal.
2. Correct answer: C The PRIORITY nursing diagnosis is C) Risk for injury related to confusion and agitation. Mr. Nguyen’s confusion and agitation, stemming from alcohol withdrawal, make him a high risk for falls and other injuries. While the other options (A, B, and D) are relevant diagnoses, they are not the immediate priority in ensuring Mr. Nguyen’s safety.
3. Correct answer: D The most appropriate intervention to address Mr. Nguyen’s fall risk is D) Use bed alarms as part of a comprehensive fall prevention program. This proactive measure helps alert staff of attempts to get out of bed, reducing fall risk. Option A increases fall risk as it reduces monitoring. Option B, while helpful, is not the immediate priority. Option C might not be feasible or provide consistent monitoring.
4. Correct answer: B The medication the nurse should administer FIRST is B) Chlordiazepoxide. Chlordiazepoxide is a benzodiazepine used to treat alcohol withdrawal symptoms, including agitation and confusion. Addressing Mr. Nguyen’s alcohol withdrawal symptoms is a priority as they significantly contribute to his risk for injury. While the other medications are important for managing his other conditions, they are not the immediate priority.
5. Correct answer: A The BEST action for the nurse to take is A) Continue to monitor Mr. Nguyen’s vital signs, CIWA-Ar results, and for signs of alcohol withdrawal. It’s crucial to monitor for ongoing symptoms and medication effectiveness because Chlordiazepoxide is short acting and used as needed. Option B is incorrect as pain medication should not be administered based solely on a client’s calmness. Option C is incorrect as the client is still at risk for falls. Option D is not necessary as the Chlordiazepoxide is written as needed.
6. Correct answer: A The most EFFECTIVE outcome in evaluating the goal of healthy coping is A) Client expresses desire to participate in a group session about alcohol use disorder. Participating in a group session about alcohol use disorder will help the client learn how to adapt from other clients with similar challenges. The other options are relevant to Mr. Nguyen’s overall care but don’t specifically address the goal of healthy coping.

Please find answers to the Learning Activity interactive elements within the element.