Which action should the nurse implement first for a client experiencing alcohol withdrawal?

Correct Answer: D

Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.

Correct Answer: D

Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.

Correct Answer: C

Rationale: The correct answer is to assess the client's risk for suicide. When a client expresses feelings of hopelessness and helplessness, it indicates a high risk of self-harm or suicide. Therefore, the priority intervention should be to assess the client's safety. Encouraging the client to join a support group (choice A) may be beneficial but not the priority at this time. Referring the client for cognitive-behavioral therapy (CBT) (choice B) and suggesting daily exercise (choice D) are important interventions in managing depression but assessing the risk for suicide takes precedence due to the immediate safety concern.

Correct Answer: D

Rationale: Encouraging the client to express his feelings about relapse is the most appropriate action for the nurse to take in this situation. This approach allows the nurse to address the underlying emotions and factors contributing to the relapse. Choice A, asking the client why he started drinking again, may come across as judgmental and might not be as effective in exploring the client's emotions. Choice B, providing information about support groups, is important but should come after addressing the client's current emotional state. Choice C, discussing the consequences of drinking, may be necessary at some point, but initially, the focus should be on the client's feelings and emotions surrounding the relapse.

Correct Answer: C

Rationale: The statement 'I can drink alcohol in moderation while taking this medication' indicates a need for further teaching because alcohol consumption can have dangerous interactions with MAOIs. MAOIs can interact with alcohol to cause a hypertensive crisis, which can be life-threatening. Choices A and B are correct statements as avoiding tyramine-rich foods and taking the medication with food can help prevent adverse effects. Choice D is incorrect because abruptly stopping an antidepressant medication like an MAOI can lead to withdrawal symptoms and a relapse of depression.