Alcoholism Case Study Section 2

Section 2 Admission to the Crisis Unit When the client is admitted to the Crisis Unit, the nurse understands it is best to maintain a quiet, calm environment to help relax and decrease nervous system irritability. The nurse must assign a room and search belongings. Question 5 of 25 Which items can the nurse allow the client to keep in the room? (Select all that apply.). Unlaced tennis shoes. The client can keep tennis shoes. Tennis shoes without laces do not typically pose a threat. Keltner, N., Steele, D. (2019) Psychiatric Nursing (8th edition), St. Louis, Missouri. Elsevier. Pg. 94, Aftershave lotion. Aftershave lotion contains alcohol, and this is contraindicated for the client. Electronic book reader. The client may keep an electonic book reader, but it cannot connect to the internet. The client must keep the battery's charging cord at the nurse's desk and the staff may charge the battery if needed. Keltner, N., Steele, D. (2019) Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 94. An electronic cigarette. All cigarettes, including an e-cigarette, must be kept at the nurse's desk to ensure that the client doesn't try to smoke in the hospital A personal photo. The client can keep a personal photo. This does not pose a threat and may help the client feel more comfortable in the environment. Keltner N Steele 1 2011 Pochiatric Nursine (8th edition) St Louis Miscuri Flevier. Pe 94 Question 6 of 25 Which priority nursing problems should be addressed within 72 hours of admission? (Select all that apply.) Ineffective denial. The client's denial is a defense mechanism that reduces anxiety, but in considering problems according to Maslow's hierarchy, it is not a priority. Risk for injury. Risk for injury related to the client's thoughts of wanting to jump off a bridge is a priority nursing problem and the rationale for admission to the crisis unit. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier, Pg. 90. Ineffective coping. Ineffective coping is a problem related to inadequate coping skills, but other nursing problems should be addressed first. Altered nutrition. Nutrition is very important because a client with alcohol dependency drinks alcohol instead of eating nourishing food, causing malabsorption of essential vitamins. Deficiency and malabsorption of vitamin 8 can cause Wernicke's disease, a severe problem with decreased cognitive functioning. Keltner, N., Steele, D. (2019). Psychiatric Nursing (8th edition). St. Louis, Missouri. Elsevier. Pg. 90. Risk for withdrawal. Alcohol withdrawal can occur as early as 4-to-6 hours after the client's last drink. Keltner, N., Steele, D. (2019), Psychiatric Nursing (8 edition). St. Louis, Missouri. Elsevier. Pg. 90. Routine admission orders include regular diet, nutrition consultation, vital signs every 4 hours, CBC with differential, urinalysis, and urine drug screen. The HCP also orders acetaminophen 325 mg by mouth (PO) every 6 hours as needed (PRN) for pain, fever, or headache. Question 7 of 25 Which routine admission order should the nurse question? A regular diet. A regular diet is appropriate for the client based on an assessment. Vital signs every 4 hours. Vital signs every 4 hours is routine and applicable for the client. Acetaminophen as needed. The client is suspected of having liver problems due to alcohol. Acetaminophen can be toxic to the liver, especially in combination with alcohol. The nurse should question this order as it is contraindicated for the client. Skidmore-Roth, L (2021). Mosby's 2021 Nursing Drug Reference. (34th edition). St. Louis, Missouri. Elsevier. Pg. 12. Keltner, N., Steele, D. (2019), Psychiatric Nursing (8th edition), St. Louis, Missouri. Elsevier, Pg. 381. Urinalysis and urine drug screen. This is a routine admission order and is appropriate for the client. Submit Question 8 of 25