A client who has been using large amounts of alcohol for years is admitted for withdrawal management and suddenly becomes disoriented and combative. What is the primary nursing concern in this situation?
Development of delirium tremens
Risk of suicide
Risk of falling
Need for nutritional assessment
The Correct Answer is A
A. Delirium tremens (DTs) is a severe and life-threatening complication of alcohol withdrawal that typically occurs 48 to 72 hours after the last drink. It is characterized by disorientation, agitation, confusion, hallucinations, tachycardia, hypertension, fever, and diaphoresis. Sudden disorientation and combative behavior in a client with long-term heavy alcohol use strongly suggest the development of DTs, which requires immediate medical intervention to prevent seizures, cardiovascular collapse, or death. Therefore, this is the primary nursing concern.
B. Although clients experiencing alcohol withdrawal may have coexisting depression or suicidal ideation, the immediate presentation of acute disorientation and combativeness indicates a physiologic withdrawal complication rather than suicidal intent. Suicide risk assessment is important but not the priority in this acute scenario.
C. Risk of falling is a valid concern because disorientation and agitation increase the likelihood of injury. However, this is a secondary safety concern. The underlying cause—possible delirium tremens—is life-threatening and must be addressed first.
D. Nutritional deficiencies, such as thiamine deficiency, are common in chronic alcohol use and should be assessed and treated. However, nutritional assessment is not the immediate priority when the client shows acute signs of severe withdrawal and altered mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Aphasia is a language disorder that affects the ability to speak, understand, read, or write. While it impacts communication, it does not involve the inability to recognize familiar objects or people, so it is not the correct answer.
B. Agnosia is the inability to recognize or identify objects, people, sounds, shapes, or smells despite intact sensory function. In this scenario, the patient cannot recognize a family member visually, which is characteristic of visual agnosia, a subtype of agnosia. This condition is often associated with brain injury or damage to the occipital or temporal lobes.
C. Agraphia refers to the inability to write, usually due to brain injury affecting language or motor areas. It does not involve recognition of people or objects.
D. Apraxia is the inability to perform purposeful movements or carry out learned motor tasks despite having the physical ability and desire to do so. It does not impair recognition of familiar individuals.
Correct Answer is D
Explanation
A. Schizotypal personality disorder is characterized by eccentric behavior, odd beliefs, and social anxiety, not a blatant disregard for rules or instructions. The client’s defiance and rule-breaking do not align with this disorder.
B. Narcissistic personality disorder involves grandiosity, need for admiration, and lack of empathy, but it does not inherently include persistent refusal to follow rules or disregard for authority. The client may challenge others but usually to gain attention or validation rather than consistently violate rules.
C. Histrionic personality disorder is characterized by attention-seeking, dramatic behavior, and emotional exaggeration. Defiance of rules is not a primary feature.
D. Antisocial personality disorder is correct. antisocial personality disorder is marked by a pattern of disregard for, and violation of, the rights of others, impulsivity, deceitfulness, and failure to conform to social norms or rules. The client’s refusal to follow instructions and claim that unit rules do not apply reflects classic manifestations of antisocial personality traits.
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