A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

Tolerance

Addiction

Alcoholism

Relapse

Answer and Explanation

The Correct Answer is A

A. Tolerance: Tolerance occurs when an individual requires increasing amounts of a substance to achieve the same effect. This can explain why a person with a high blood alcohol level might not appear intoxicated if they have developed tolerance.

B. Addiction: Addiction is a chronic disease involving compulsive substance use. While related to tolerance, addiction itself does not specifically explain the lack of observable intoxication symptoms.

C. Alcoholism: Alcoholism is a condition involving dependency on alcohol. It can involve tolerance, but the term "alcoholism" does not specifically address the immediate observation of high alcohol levels without visible intoxication.

D. Relapse: Relapse refers to returning to substance use after a period of abstinence. It does not specifically explain the lack of visible intoxication despite high blood alcohol levels.

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Correct Answer is A

Explanation

A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.

B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.

C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.

D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.

A. Alcohol tolerance B. Korsakoff's psychosis C. Delirium tremens D. Wernicke's encephalopathy

Correct Answer is C

Explanation

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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A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

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