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.
Explanation & Rationale
A. Smoking history: Although the client quit smoking over 20 years ago, there is no immediate concern with their smoking history in this admission. The focus is on the current alcohol-related issues, as smoking history does not have a direct, immediate impact on the client's current condition. B. Client's recent consumption of alcohol: The client has a history of alcohol use disorder and has been drinking continuously since the death of their parents. Monitoring alcohol consumption and its effects is crucial for evaluating withdrawal symptoms and preventing complications like delirium tremens, which can occur in severe alcohol withdrawal. C. Blood alcohol level: Since the client has consumed alcohol recently (within the past 2 hours), it is important to assess their blood alcohol level to determine the extent of intoxication and potential risks associated with alcohol withdrawal. This helps guide immediate management and interventions. D. Client's recent loss: The death of the client's parents is a significant stressor that likely contributed to the relapse in alcohol use. This emotional distress should be addressed as part of the care plan, as it may be influencing the client's mental and emotional state, which can impact their recovery process. E. Respiratory assessment: The client has a respiratory rate of 10/min, which is low and could be indicative of respiratory depression, especially if the client is intoxicated or if withdrawal symptoms are imminent. Monitoring respiratory status is important to ensure adequate oxygenation and detect early signs of respiratory distress. F. Neurological assessment: The client is intoxicated and exhibiting slurred speech, which suggests neurological impairment. It is important to monitor the client's neurological status for any signs of complications such as confusion, altered consciousness, or the onset of alcohol withdrawal seizures or delirium. G. Cardiac assessment: The client has a normal heart rate and rhythm upon initial assessment, and there is no indication of cardiovascular distress. While cardiovascular monitoring is important, the client's current condition does not show any immediate signs that require further follow-up. H. Gastrointestinal assessment: Although the client reports weight loss and a minimal appetite, these findings are likely related to their alcohol use disorder and could be addressed as part of the ongoing management of the condition. However, this does not require immediate follow-up compared to the more urgent issues related to intoxication and withdrawal. I. Genitourinary assessment: The client reports no known problems, and there are no immediate concerns about their genitourinary system. This assessment is less of a priority at this time compared to monitoring for alcohol-related issues.