Page 2317 - Saunders Comprehensive Review For NCLEX-RN

Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Mental Health
Health Problem: Mental Health: Addictions
Priority Concepts: Addiction; Communication
Reference: Varcarolis (2017), p. 331.

818. Answer: 1, 2, 3, 5

Rationale: When the client is experiencing withdrawal from alcohol, the priority
for care is to prevent the client from harming self or others. The nurse would
monitor the vital signs closely and report abnormal findings. The nurse would
provide a low-stimulation environment to maintain the client in as calm a state as
possible. The nurse would reorient the client to reality frequently and would address
hallucinations therapeutically. Adequate nutritional and fluid intake need to be
maintained.
Test-Taking Strategy: Note the strategic words, most appropriate. Thinking about
the needs of the client in alcohol withdrawal and recalling the characteristics
associated with alcohol withdrawal will assist in answering correctly. Also, use
therapeutic communication techniques to assist in selecting the correct
interventions.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Addictions
Priority Concepts: Addiction; Caregiving
Reference: Varcarolis (2017), p. 303.

819. Answer: 1

Rationale: Al-Anon support groups are a protected, supportive opportunity for
spouses and significant others to learn what to expect and to obtain excellent
pointers about successful behavioral changes. The correct option is the healthiest
response because it exemplifies an understanding that the alcoholic partner is
responsible for his behavior and cannot be allowed to blame family members for loss
of control. Option 2 is incorrect, because the nonalcoholic partner should not feel
responsible when the spouse loses control. Option 3 indicates that the group is
viewed as an escape, not as a place to work on issues. Option 4 indicates that the
wife remains codependent.
Test-Taking Strategy: Focus on the subject, the therapeutic effect of attending an
Al-Anon group. Noting the words benefiting from attending an Al-Anon group will
direct you to the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Evaluation

2317