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Question

Difficulty: MediumHigh Risk Behaviors

A practical nurse (PN) is providing in-home care for a client recovering from a recent cerebrovascular accident. While assisting with morning hygiene, the PN discovers several empty liquor bottles concealed in the bathroom linen closet and observes that the client is experiencing mild bilateral hand tremors. Which of the following is the most appropriate initial action for the PN to take?

  1. Document the objective findings and report them to the supervising registered nurse.Answer
  2. B
    Ask the client, "Why are you hiding these bottles in your closet?"
  3. C
    Initiate a formal referral to an outpatient substance use recovery program.
  4. D
    Inform the client's visiting family members about the discovery to ensure a safe environment.

Answer

The most appropriate initial action is to document the objective findings and report them to the supervising registered nurse.
The correct action is to document the objective findings and notify the supervising registered nurse. Discovering concealed alcohol and noting physical symptoms like tremors suggests a high-risk behavior (substance misuse) and potential alcohol withdrawal. The practical nurse must escalate these new, significant findings to the RN, who is responsible for comprehensive assessment, modifying the nursing care plan, and coordinating interdisciplinary referrals.

Step-by-Step Solution

1
Identify the clinical cues presented in the scenario.
The client has hidden liquor bottles and is exhibiting hand tremors.
Recognizing signs of high-risk behavior (alcohol misuse) and potential physical withdrawal is the first step in clinical judgment.
2
Determine the role and scope of the practical nurse regarding these findings.
The PN is responsible for data collection and reporting to the RN, but cannot independently alter the care plan or initiate referrals.
Scope of practice guidelines dictate that RNs must synthesize new complex data and manage interdisciplinary referrals.
3
Evaluate the remaining options for safety, confidentiality, and therapeutic communication.
Confronting the client with a "why" question is non-therapeutic, and discussing the issue with family violates HIPAA regulations.
Maintaining confidentiality and using therapeutic communication are fundamental nursing responsibilities that must not be bypassed.

Key Concept

High Risk Behaviors and PN Scope of Practice
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Topics

High Risk Behaviors

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