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SIMULATION REAL LIFE MENTAL HEALTH ALCOHOL USE DISORDER Solution

Scenario Nurse Stacy completes the admission assessment of Mr. Moore. Question Nurse Stacy is completing the admission process for Mr. Moore. Which of... [Show More] the following nursing assessments should Stacy complete? (Select all that apply) Selected Option Fall risk assessment Numeric pain scale Braden scale CAGE questionnaire Rationale The fall risk assessment is used for clients who have a risk factor of falling, such as those with confusion and substance use disorder. BEST ANSWERBest Decision Scenario Nurse Stacy completes an assessment of possible alcohol use disorder using the CAGE questionnaire. Question Nurse Stacy plans to complete the CAGE questionnaire as part of her nursing assessment. Which of the following questions is included in this questionnaire? Selected Option Have you ever felt bad or guilty about your drinking? Rationale This is one of the four questions asked when administering the CAGE questionnaire. BEST ANSWERBest Decision Scenario Nurse Stacy anticipates a medication prescription for Mr. Moore, who is in acute alcohol withdrawal. Question Nurse Stacy is caring for Mr. Moore, who is in acute alcohol withdrawal. She should anticipate the provider will prescribe which of the following medications? Selected Option Lorazepam (Ativan) Rationale Lorazepam is a benzodiazepine, which commonly is ised to treat acute alcohol withdrawal. Essay Response Scenario Nurse Stacy notifies Dr. Edwards of a change in Mr. Moore's condition. Question Using the SBAR format, Nurse Stacy calls Dr. Edwards and reports her assessment findings. What should she include in her report? (Fill in the blank and click on the submit button when you finish.) Selected Option Situation: At 0200, discovered client lying at foot of bed, disheveled, saline lock dangling from arm. Client awake and responsive. Background: 45 year-old-white male who had MVA yesterday at approximately 1400. Admitted by ambulance in acute alcohol intoxication with abrasions and accompanied by police. History of gastritis and esophagitis. Transferred to medical-surgical unit. No change in status prior to this time. Assessment: Alert to person and place, but not time. States he has nausea with dry heaves. Moderate tremor of upper extremities. Appears moderately anxious and restless. No auditory or visual disturbances. States: “I feel the bugs all over me.” Reports mild headache. Vital signs: BP 160/94; T 37.9; P 106, and R 24, which are elevated from midnight findings. CIWA score of 23. Recommendation: Needs antiemetic and medication for agitation and withdrawal. Rationale Situation: At 200, discovered client lying at foot of bed, disheveled, saline lock dangling from arm. Client awake and responsive. Background: 45-year-old white male who had MVA yesterday at approximately 1400. Admitted by ambulance in acute alcohol intoxication with abrasions and accompanied by police. History of gastritis and esophagitis. Transferred to medical-surgical unit. No change in status prior to this time. Assessment: Alert to person and place, but not time. States he has nausea with dry heaves. Moderate tremor of upper extremities. Appears moderately anxious and restless. No auditory or visual disturbances. States: “I feel the bugs all over me.” Reports mild headache. Vital signs: BP 160/94; T 37.9; P 106, and R 24, which are elevated from midnight findings. CIWA score of 23. Recommendation: Needs antiemetic and medication for agitation and withdrawal. BEST ANSWERBest Decision Scenario Nurse Stacy implements seizure precautions for Mr. Moore. Question Nurse Stacy implements seizure precautions for Mr. Moore. Which of the following should Stacy include in the plan of care? Selected Option Have suction equipment available in Mr. Moore’s room. Rationale Suction equipment is needed as part of seizure precautions. BEST ANSWERBest Decision Scenario Nurse Stacy is planning care for Mr. Moore, who is in alcohol withdrawal. Question Nurse Stacy is planning care for Mr. Moore. Which of the following nursing interventions is appropriate for a client in alcohol withdrawal? Selected Option Promote a low-stimulation environment. Rationale A low-stimulation environment promotes rest and energy conservation, and is calming for the client. CORRECT Scenario Nurse Stacy calculates the rate of administration of the piggyback medication. Question Nurse Stacy is preparing to administer an intermittent IV bolus of ranitidine (Zantac) 50 mg in 0.9% sodium chloride 100 mL over 20 min. Stacy should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number.) Selected Option 300 Rationale STEP 1: What is the unit of measurement to calculate? mL/hr STEP 2: What is the volume needed? 100 mL STEP 3: What is the total infusion time? 20 min STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 60 min/20 min = 1 hr/X hr X = 0.333 hr STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 100 mL/0.333 hr = X mL/hr X = 300.3 STEP 6: Round if necessary. 300.3 = 300 STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 100 mL to infuse over 20 min, it makes sense to administer 300 mL/hr. The nurse should set the IV pump to deliver rantidine 50 mg in 100 mL 0.9% sodium chloride IV at 300 mL/hr. BEST ANSWERBest Decision Scenario Mr. Moore lacks understanding of the importance of thiamine (vitamin B1). Question Nurse Stacy is preparing to review the importance of thiamine (vitamin B1) replacement therapy with Mr. Moore. Which of the following statements should be included in this discussion? Selected Option “This medication works on the nervous system to prevent encephalopathy.” Rationale A deficiency of thiamine can result in Wernicke-Korsakoff syndrome. BEST ANSWERBest Decision Scenario Mr. Moore demonstrates maladaptive coping mechanisms in interactions with hospital personnel. Question Mr. Moore had interactions with hospital personnel earlier in the day. Which of the following videos is an example of Mr. Moore’s use of denial as a maladaptive coping mechanism? (Review each of the videos. After making your selection, click on the submit button.) Selected Option Mr. Moore talks to Social Worker Eva about going out for drinks at the end of the day with other construction workers. (THE LAST VIDEO) Rationale The client uses denial when he refuses to admit he has an alcohol use disorder while talking with the social worker. BEST ANSWERBest Decision Scenario Nurse Stacy offers a therapeutic response to Mr. Moore, who is using the defense mechanism of denial. Question Mr. Moore states he does not have a problem with alcohol. Which of the following is a therapeutic response to this statement by Nurse Stacy? Selected Option “So you don’t think you’re an alcoholic?” Rationale This is an appropriate use of the therapeutic technique of restating. BEST ANSWERBest Decision Scenario Nurse Steve and Social Worker Eva review medications that are prescribed in outpatient treatment programs to decrease alcohol cravings. Question Discharge planning includes teaching Mr. Moore about medications prescribed to decrease his alcohol craving. Which of the following medications are appropriate to include in this discussion? (Select all that apply.) Selected Option Topiramate (Topamax) Naltrexone (Revia) Rationale Naltrexone, an opioid antagonist, and topiramate, an anticonvulsant, can decrease alcohol use by reducing the client’s craving for alcohol. Disulfiram does not decrease craving for alcohol, but can motivate clients to abstain because of the medication’s unpleasant adverse effects if taken with alcohol. Chlordiazepoxide is a benzodiazepine used to facilitate withdrawal from alcohol but it does not decrease craving. Methadone is used to treat opioid craving, not alcohol craving [Show Less]

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