Practice Question
A client with a history of alcohol use disorder is prescribed disulfiram. During a follow-up visit, the client reports experiencing nausea and heart palpitate .Which of the following interventions should the nurse implement first?
Answer Choices:
Correct Answer:
Determine the client's medication adherence and recent alcohol intake.
Rationale:
🔶Disulfiram works by causing an aversive reaction if the client consumes alcohol, leading to symptoms like nausea, flushing, tachycardia, and palpitations.
🔶When a client on disulfiram reports nausea and heart palpitations, the priority is to assess for possible alcohol exposure (drinks, cough syrups, sauces, mouthwash).
🔶Determining medication adherence and recent alcohol intake helps identify whether the client is experiencing a disulfiram–alcohol reaction, which can become serious.
🔶Assessment is always the first step in the nursing process and guides further interventions and safety measures.
🔶Thus, this option is priority because it directly addresses the likely cause of symptoms and informs urgent next steps.
Check the client's blood sugar for hypoglycemia
🔶Although nausea and palpitations can occur with hypoglycemia, the client’s key risk factor here is disulfiram therapy with alcohol use disorder.
🔶The symptoms described strongly suggest a potential disulfiram–alcohol reaction, which must be assessed first.
🔶Jumping to blood sugar testing without exploring recent alcohol use misses the most probable and dangerous cause in this context.
🔶Blood sugar assessment might be indicated later if other risk factors exist, but it is not the first-line priority.
🔶Therefore, this option is incorrect as a first action, given the medication and history.
Review the client's liver function tests for signs of hepatic encephalopathy.
🔶Liver function tests are important in chronic alcohol use and hepatotoxic medications, but they do not immediately explain acute nausea and palpitations in a client on disulfiram.
🔶Hepatic encephalopathy presents with confusion, altered mental status, and asterixis, not primarily with palpitations after disulfiram use.
🔶This option focuses on a long-term complication rather than the acute potential medication–alcohol reaction.
🔶While monitoring liver function is important, it is not the priority in this specific scenario.
🔶Therefore, it is incorrect as the first intervention.
Evaluate the client's dietary intake for vitamin deficiencies.
🔶Clients with chronic alcohol use are at risk for vitamin deficiencies (e.g., thiamine, folate), but these deficiencies do not typically cause acute nausea and palpitations after disulfiram.
🔶Assessing diet is a health promotion and long-term management activity, not an acute safety response.
🔶Focusing on dietary intake at this time delays the essential assessment of recent alcohol exposure, which may signal a dangerous reaction.
🔶Nurses must first address issues that could lead to immediate cardiovascular collapse or severe reaction.
🔶Thus, this answer is incorrect as a first-line intervention.
Want to practice more questions like this?
This question is from LPN Mental Health NSG 2320 Exam which contains 45 questions.
More Questions from This Exam
A client experiencing high levels of stress is interested in complementary and alternative therapies to help achieve a calming effect. Which of the following therapies involving the use of essential oils should the nurse recommend?
Answer Choices:
A nurse is caring for a client taking lithium for bipolar disorder. The client reports nausea, muscle weakness, and hand tremors. The nurse reviews the client laboratory results and notes a lithium level of 2.0 mEq/L. Which of the following is the nurse's priority action?
Answer Choices:
A nurse is reinforcing teaching with a client diagnosed with major depressive disorder. Which of the following statements made by the client indicates an understanding of the teaching?
Answer Choices:
A client with bipolar disorder is experiencing mania and has been very active and displaying high energy levels. Which of the following interventions should the nurse prioritize while caring for this client?
Answer Choices:
A client has been experiencing high levels of work-related stress. Which of the following behaviors is an example of a maladaptive coping strategy?
Answer Choices:
Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: 💎Examplify-PN
- Domain: 🤦🏼♀️ Mental Health-PN
- Answer Choices: 4