Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5020

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5020

QUESTION: A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority?

✓O a.) Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output
✘O b.) Checking the client's medical records for health history information
✘O c.) Attempting to contact the client's family to obtain more information about the client
✘O d.) Restricting fluids and leaving the client alone to "sleep off" the episode

RATIONALE

RATIONALE: A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the care plan. Fluids are typically increased unless contraindicated by a preexisting medical condition.
NURSING PROCESS STEP: Planning
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Knowledge