A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

Alcohol tolerance

Korsakoff's psychosis

Delirium tremens

Wernicke's encephalopathy

Answer and Explanation

The Correct Answer is C

A. Alcohol tolerance: Alcohol tolerance refers to the decreased effect of alcohol with repeated use, not withdrawal symptoms.

B. Korsakoff's psychosis: Korsakoff's psychosis is a chronic condition related to thiamine deficiency and characterized by memory impairment and confabulation, not acute withdrawal symptoms.

C. Delirium tremens: Delirium tremens (DTs) is a severe form of alcohol withdrawal that can present with tremors, agitation, elevated blood pressure, tachycardia, and confusion. The client’s symptoms and recent history suggest DTs.

D. Wernicke's encephalopathy: Wernicke's encephalopathy typically presents with ataxia, confusion, and ophthalmoplegia rather than the acute withdrawal symptoms described.

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Correct Answer is D

Explanation

A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.

B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.

C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.

D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.

A. Grab bars B. Nonslip mats C. Baseboard heaters D. A smoke detector

Correct Answer is D

Explanation

A. Grab bars: Grab bars are useful for preventing falls in the bathroom but are unrelated to the client’s atrophy of olfactory organs, which affects the sense of smell.

B. Nonslip mats: Nonslip mats can help prevent falls but are not related to the client’s diminished sense of smell.

C. Baseboard heaters: Baseboard heaters are unrelated to olfactory atrophy and do not address the safety concerns associated with a reduced sense of smell.

D. A smoke detector: A smoke detector is essential for this client because the atrophy of olfactory organs means the client may not be able to detect the smell of smoke, increasing the risk of not noticing a fire.

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A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

An elderly client is being discharged home. The client lives alone and has atrophy of his olfactory organs. The nurse tells the client's family that it is essential that the client have what installed in the home?

Correct Answer is D

Explanation

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