A patient is admitted for alcohol detoxification. The nurse observes the patient to be agitated and sweaty, with hand tremors. What is the priority nursing intervention?

Correct Answer: D

Rationale: The correct answer is D) Assess for signs of withdrawal. In this scenario, the priority nursing intervention is to assess for signs of withdrawal because the patient is exhibiting symptoms like agitation, sweating, and hand tremors, which are indicative of alcohol withdrawal. Early identification of withdrawal symptoms is crucial in preventing potential complications such as seizures, delirium tremens, or even death. By assessing the patient for signs of withdrawal, the nurse can determine the severity of the withdrawal symptoms and initiate appropriate interventions promptly. Option A) Provide a quiet, calm environment, is important in managing withdrawal symptoms, but it is not the priority at this moment. Option B) Encourage the patient to drink fluids may be beneficial, but it does not address the immediate concern of assessing for withdrawal symptoms. Option C) Administer medications as prescribed may be necessary, but without a thorough assessment of withdrawal symptoms, the nurse may not know which medications are most appropriate for the patient's condition. In an educational context, this question highlights the importance of recognizing and managing alcohol withdrawal in patients. Nurses need to be able to prioritize interventions based on the patient's condition and assess for potential complications. This question reinforces the critical thinking skills required in nursing practice to ensure patient safety and well-being.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B, which is the newly admitted client who has bipolar I disorder. The rationale behind this choice lies in the acuity and potential risk associated with bipolar I disorder. This condition can involve severe mood swings, including manic episodes that may require immediate attention to ensure the safety of the client and others. Option A is incorrect because premenstrual dysphoric disorder, while significant, does not typically present an immediate threat to the client's safety that would necessitate urgent intervention. Option C, the client with disruptive mood dysregulation disorder, is also less urgent as this disorder is characterized by chronic irritability rather than acute mood disturbances that require immediate attention. Option D, the client with a history of dysthymic disorder, is not the priority as this condition is a persistent depressive disorder that does not typically involve the same level of acuity as bipolar I disorder. From an educational perspective, this question highlights the importance of prioritizing care based on the acuity of the client's condition. It emphasizes the need for nurses to assess and manage clients with more acute and potentially dangerous conditions first to ensure their safety and well-being.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Displaying extreme mood swings. This behavior is a potential warning sign of suicide because extreme mood swings, especially sudden shifts from extreme sadness to extreme calmness, can indicate an individual struggling with significant emotional distress. Option A, seeking a tutor for help with a challenging class, is a healthy and proactive behavior that shows a student's willingness to seek academic support. While academic struggles can contribute to stress, it is not typically a direct warning sign of suicide. Option B, volunteering at a homeless shelter, demonstrates empathy and community involvement. Engaging in volunteer work is generally a positive behavior that promotes social connection and a sense of purpose, factors that can actually protect against suicide. Option C, making plans to go to a high school dance, is a typical social activity for high school students. While changes in social behavior can sometimes be linked to mental health issues, simply attending a dance is not a specific warning sign of suicide. In an educational context, it is crucial for nurses and educators to be able to identify potential warning signs of suicide in students. By recognizing behaviors such as extreme mood swings, professionals can intervene early and connect students to appropriate support services to prevent tragic outcomes. Providing this knowledge equips school staff to create a safe and supportive environment for students' mental health and well-being.

Correct Answer: C

Rationale: In this scenario, option C, "It may take several weeks for the full effects of the medication to be felt," is the correct choice for the nurse to include in the patient's teaching plan. This is because fluoxetine, like other selective serotonin reuptake inhibitors (SSRIs), typically takes a few weeks to reach its full therapeutic effect in treating major depressive disorder. It is crucial for the patient to understand that immediate improvement in symptoms is unlikely and that adherence to the medication regimen is essential for long-term benefits. Option A, stating that the patient may experience drowsiness and sedation during the day, is not a priority teaching point for fluoxetine. While these side effects can occur, they are more commonly associated with other medications and typically diminish over time with continued use. Option B, suggesting that the patient may notice improvement in mood within a few hours, is inaccurate and misleading. Immediate mood improvement is not expected with fluoxetine and may lead to unrealistic expectations and premature discontinuation of the medication. Option D, advising the patient to take the medication with food to reduce stomach upset, is a general recommendation for SSRIs but is not as critical as understanding the delayed onset of therapeutic effects. It is important to address potential side effects and optimal administration, but the timeline for experiencing the full benefits of the medication takes precedence in educating the patient effectively. In an educational context, this question highlights the importance of providing accurate information to patients regarding their medication regimen. Nurses play a crucial role in patient education, empowering individuals to make informed decisions about their health. By understanding the pharmacokinetics and expected outcomes of medications, patients can better manage their conditions and adhere to treatment plans for improved health outcomes.

Correct Answer: C

Rationale: In this scenario, the correct intervention (Option C) for the nurse to prioritize is assisting the patient in developing coping strategies for managing flashbacks. This is crucial in helping the patient learn effective ways to deal with the distressing symptoms of PTSD. By teaching the patient coping mechanisms such as grounding techniques, deep breathing exercises, or mindfulness practices, the nurse empowers the patient to regain a sense of control over their experiences. Option A, encouraging the patient to talk about the trauma and relive the experience, could potentially retraumatize the patient and exacerbate their symptoms. Patients with PTSD may not be ready or able to recount traumatic events, and pushing them to do so can be harmful. Option B, providing education on the effects of PTSD, is important but may not be the most immediate priority in this situation. While education is valuable, addressing the patient's current distress should take precedence. Option D, reassuring the patient that the flashbacks will stop on their own over time, oversimplifies the complexities of PTSD and may give false hope. Effective management of PTSD requires active coping strategies and support, rather than passive waiting for symptoms to resolve on their own. In an educational context, understanding the rationale behind prioritizing coping strategies for managing flashbacks in patients with PTSD highlights the importance of patient-centered care, trauma-informed practice, and evidence-based interventions in nursing practice. By focusing on empowering patients with practical tools to manage their symptoms, nurses can make a significant positive impact on the well-being and recovery of individuals with PTSD.