Emergency Nursing & Triage Q 16 - Gyan Darpan : Learning Portal
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Thursday 24 March 2022

Emergency Nursing & Triage Q 16

An intoxicated client comes into the emergency unit with uncooperative behavior, mild confusion, and slurred speech. The client is unable to provide a good history but he verbalizes that he has been drinking a lot. Which of the following is a priority action of the nurse?
    A. Administer IV fluid incorporated with Vitamin B1 as ordered
    B. Administer Naloxone (Narcan) 4 mg as ordered
    C. Contact the family to get information about the client
    D. Obtain an order for the determination of blood alcohol level

Correct Answer: A. Administer IV fluid incorporated with Vitamin B1 as ordered.

The client has symptoms of alcohol abuse and there is a risk for Wernicke syndrome, which is caused by a deficiency in Vitamin B. Thiamine deficiency (vitamin B1) is common in patients with alcohol dependence. Cognitive impairments may be an early consequence of thiamine deficiency. Wernicke’s encephalopathy is underdiagnosed and undertreated.

Option B: Multiple drug abuse is not uncommon; however, there is currently nothing to suggest an opiate overdose that requires the administration of naloxone. Naloxone is indicated for the treatment of opioid toxicity, specifically to reverse respiratory depression from opioid use. It is useful in accidental or intentional overdose and acute or chronic toxicity.
Option C: Teens and young adults are at higher risk for binge drinking, which can cause alcohol poisoning. Binge drinking is a pattern of drinking that raises the blood alcohol level within a short period of time. Though it varies from person to person, binge drinking is usually defined as four drinks for women and five drinks for men in a two-hour period.
Option D: Additional information or the results of the blood alcohol testing are part of the management but should not delay the immediate treatment. A blood alcohol test may be used to find out if the patient has alcohol poisoning, a life-threatening condition that happens when the blood alcohol level gets very high. Alcohol poisoning can seriously affect basic body functions, including breathing, heart rate, and temperature.

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