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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "Are you frightened?" This response is empathetic but may inadvertently reinforce the client's delusional thinking by focusing on the fear rather than addressing the delusion.

B. "You know I'm not following you." This response directly challenges the client's delusion, which could provoke defensiveness and escalate the situation.

C. "You'll have to go into seclusion if you continue to threaten me." This response is confrontational and may escalate the situation further by implying a threat, which could increase the client's fear and anger.

D. "I'm sorry if I frightened you. I was returning to the nurses' station after going out for lunch." This response acknowledges the client's feelings without reinforcing the delusion and provides a simple, non-threatening explanation for the nurse's actions. It helps de-escalate the situation by maintaining a calm, non-confrontational tone.

A. The client can obtain and maintain employment. B. The client is free from aggressive behaviors. C. The client utilizes relaxation techniques. D. The client maintains healthy relationships with others.

Correct Answer is B

Explanation

A. The client can obtain and maintain employment. While obtaining and maintaining employment can be a positive outcome, it does not specifically address the control of aggressive behaviors which are the focus here.

B. The client is free from aggressive behaviors. Being free from aggressive behaviors directly reflects successful treatment of aggressive symptoms in schizophrenia. This outcome specifically addresses the primary concern.

C. The client utilizes relaxation techniques. Utilizing relaxation techniques can be part of managing symptoms but does not directly measure the control of aggressive behaviours.

D. The client maintains healthy relationships with others. Maintaining healthy relationships is a positive outcome, but it is a broader goal and does not directly indicate control of aggressive behaviours.

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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?

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Naxlex Comprehensive Predictor Exams

As a nurse approaches the nurses' station, a client diagnosed with a delusional disorder raises his voice and says, "You're following me. What do you want?" To prevent escalating fear and anger, the nurse takes a nonthreatening posture and makes which response in a calm voice?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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