A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Choice A: Gastrointestinal assessment The client reports weight loss and minimal appetite over the past 3 months. This is significant because chronic alcohol use can lead to malnutrition, gastrointestinal issues, and liver damage. Weight loss and poor appetite may indicate underlying conditions such as gastritis, pancreatitis, or liver disease, which require further evaluation and intervention. Choice B: Smoking history The client quit smoking over 20 years ago and has no current respiratory issues. While smoking history is important for a comprehensive health assessment, it does not require immediate follow-up in this context as it is not directly related to the current acute issues of alcohol intoxication and potential withdrawal. Choice C: Blood alcohol level The client’s blood alcohol level (BAC) is 310 mg/dL, which is significantly elevated (normal range: 0 to 50 mg/dL). This level of intoxication can lead to severe complications such as respiratory depression, aspiration, and even death. Immediate medical intervention is necessary to manage the acute effects of alcohol intoxication and to monitor for withdrawal symptoms. Choice D: Client’s recent loss The recent death of the client’s parents is a significant emotional stressor that has contributed to the relapse of alcohol use disorder. Addressing this loss is crucial for the client’s mental health and recovery process. The nurse should ensure that the client receives appropriate psychological support and counseling to cope with this loss1. Choice E: Genitourinary assessment The client reports no known genitourinary problems. Therefore, this area does not require immediate follow-up in the context of the current admission for alcohol use disorder. Choice F: Client’s recent consumption of alcohol The client had their last drink 2 hours ago. This information is critical for monitoring potential alcohol withdrawal symptoms, which can begin within a few hours after the last drink and can be life-threatening if not properly managed. Close monitoring and timely intervention are essential Choice G: Neurological assessment The client is intoxicated, has slurred speech, and is unable to coherently respond to questions. These neurological symptoms indicate significant alcohol intoxication and the potential for withdrawal symptoms. Continuous neurological assessment is necessary to monitor for any changes in mental status and to prevent complications. Choice H: Cardiac assessment The client has a normal sinus rhythm and palpable pulses with no history of heart disease. While cardiac assessment is always important, there are no immediate concerns in this context that require follow-up. Choice I: Respiratory assessment The client’s respiratory rate is 10/min, which is on the lower end of normal (normal range: 12-20/min). However, the client has clear lungs and no shortness of breath. While respiratory status should be monitored, it is not an immediate concern requiring follow-up in this context.