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 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.

A. client's anxiety level decreased B. client's pain level decreased C. assessment completed D. client understood the importance of the assessment

Correct Answer is B

Explanation

A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.

B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.

C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.

D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.

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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 psychiatric mental-health nurse is evaluating the treatment plan of an adult client diagnosed with schizophrenia disorder with aggressive behaviors. Which outcome of the client would demonstrate successful treatment?

Correct Answer is B

Explanation

A psychiatric-mental health nurse is conducting an initial interview with a client admitted for hallucinations and abdominal pain. The client is focused on the pain and cannot concentrate on the assessment questions being asked. What is the initial desired outcome of the client?

Correct Answer is B

Explanation

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