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. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.

B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.

C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.

D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.

A. "I feel like everyone depends on me too much." B. "Life has lost its meaning for me." C. wish I could just take a vacation and get away from it all." D. "I feel like a failure and wish one thing would just go right."

Correct Answer is B

Explanation

A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.

B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.

C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.

D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.

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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

Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

Correct Answer is D

Explanation

The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?

Correct Answer is B

Explanation

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