A 51-year-old male has been admitted to the detoxification unit with acute symptoms of alcohol withdrawal. Nursing assessment is likely to reveal what?
Tremors, headache, flushed face, and hallucinations
Psychomotor hypoactivity, hypotension, and increased appetite
Hypomania, bradycardia, and generalized seizures
Anhidrosis, hypotonicity, and delusions
The Correct Answer is A
A. Tremors, headache, flushed face, and hallucinations: Acute alcohol withdrawal commonly presents with tremors, headache, flushed face, and hallucinations. These symptoms are characteristic of withdrawal syndrome and are important to monitor.
B. Psychomotor hypoactivity, hypotension, and increased appetite: Psychomotor hypoactivity and increased appetite are not typical symptoms of acute alcohol withdrawal. Hypotension may occur, but it is not the most prominent symptom.
C. Hypomania, bradycardia, and generalized seizures: Hypomania and bradycardia are not typical for alcohol withdrawal. Generalized seizures can occur in severe cases of withdrawal (delirium tremens), but hypomania is not a common symptom.
D. Anhidrosis, hypotonicity, and delusions: Anhidrosis (lack of sweating) and hypotonicity (decreased muscle tone) are not typical for alcohol withdrawal. Delusions may occur but are not the primary symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.
B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.
C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.
D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.
Correct Answer is B
Explanation
A. Report the finding so a sleep medication can be prescribed. While this might eventually be necessary, it's premature to suggest medication without further assessing the problem. Other interventions could be tried first.
B. Clarify what the client means by trouble falling asleep. Clarifying the client's statement is essential to understand the specific nature of the sleep problem, such as how long it takes to fall asleep, how often it occurs, and whether there are any contributing factors. This is a critical step in assessment before any further action.
C. Ask the client what they do before going to bed. This is a good follow-up question, but it should come after clarification of what the client means by trouble falling asleep. Understanding pre-bedtime routines is important but secondary to defining the issue.
D. Question the client about their use of caffeine. While this is a relevant question that could affect sleep patterns, it should follow after understanding the client's specific sleep issues.
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