A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).
Tremors.
Insomnia.
Severe hypotension.
Hyperglycemia.
Visual hallucinations.
Correct Answer : A,B,E
Choice A rationale:
Tremors. Rationale: Tremors can be a withdrawal symptom associated with alcohol withdrawal. These tremors are often referred to as "alcohol shakes" and are a result of the central nervous system adapting to the sudden absence of alcohol.
Choice B rationale:
Insomnia. Rationale: Insomnia is a common withdrawal symptom during alcohol withdrawal. Alcohol disrupts sleep patterns, and when a person stops drinking, their sleep cycle may be disturbed, leading to difficulty falling asleep or staying asleep.
Choice C rationale:
Severe hypotension. Rationale: Severe hypotension, or very low blood pressure, is not a prominent withdrawal symptom of alcohol. Alcohol withdrawal can lead to an increase in blood pressure rather than severe hypotension.
Choice D rationale:
Hyperglycemia. Rationale: Hyperglycemia, or high blood sugar, is not a direct withdrawal symptom of alcohol. However, chronic alcohol use can affect blood sugar regulation over time. During acute withdrawal, hypoglycemia (low blood sugar) is more common due to altered metabolism.
Choice E rationale:
Visual hallucinations. Rationale: This statement is correct. Visual hallucinations can occur during alcohol withdrawal and are often indicative of a more severe withdrawal syndrome known as delirium tremens (DTs). DTs can include visual hallucinations, confusion, agitation, and autonomic hyperactivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Worrying about a pimple, while significant for self-esteem, does not indicate an immediate risk. Addressing more serious concerns first is crucial, although self-esteem issues should be considered subsequently.
Choice B rationale: Expressing feelings of social isolation and dislike towards peers can indicate underlying mental health concerns, such as depression or anxiety. Addressing these feelings is a priority to provide support and prevent potential escalation.
Choice C rationale: Feeling that parents treat them like a baby can be part of normal adolescent development and is not typically a priority concern unless it significantly impacts the child's well-being.
Choice D rationale: Concerns about not having started menstruation are common and usually not immediately alarming unless accompanied by other signs of developmental delay. Reassurance and providing information can address this issue effectively.
Correct Answer is D
Explanation
The correct answer is choice D: "The partner has lost 25 lbs in the past 3 months."
Choice D rationale:
This choice is the correct answer because significant weight loss in a caregiver, such as the partner of a client with Alzheimer's disease, is indicative of caregiver role strain. Caregiver role strain refers to the physical, emotional, and psychological stress experienced by caregivers due to the demands of providing care for a loved one. Weight loss in this context suggests that the partner's own health and well-being are being compromised due to the caregiving responsibilities.
Choice A rationale:
This choice might be related to safety concerns and trying to prevent the client from wandering, but it does not directly indicate caregiver role strain. Placing locks at the top of doors is a common safety measure to prevent clients with Alzheimer's disease from wandering and getting lost.
Choice B rationale:
This choice is actually a positive observation. Redirecting a frustrated client is a helpful and appropriate caregiving strategy. It indicates that the partner is actively engaged in managing the client's behavior and emotions, which is not a sign of caregiver role strain.
Choice C rationale:
Hiring a house cleaner is a practical decision and could be a sign of the partner's effort to manage their caregiving responsibilities more effectively. While it might imply a certain level of stress, it doesn't directly point to caregiver role strain as much as the significant weight loss does.
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