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. "It sounds like you're having a difficult time."
Choice A rationale:
"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.
Choice B rationale:
"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.
Choice C rationale:
"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.
Choice D rationale:
"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.
Correct Answer is B
Explanation
The correct answer is choice B. A room containing personal belongings.
Choice A rationale:
A room without a window would likely be isolating and could contribute to feelings of confusion and disorientation in a cognitively impaired individual. Natural light from windows helps regulate the circadian rhythm and provides a sense of time, which is crucial for maintaining a therapeutic environment.
Choice B rationale:
A room containing personal belongings is the correct choice. Familiar items from home can provide comfort and a sense of familiarity, reducing anxiety and agitation in cognitively impaired individuals. These belongings can act as cues for memory recall and assist in maintaining a connection to their personal identity.
Choice C rationale:
A room adjacent to the nursing station might lead to increased noise and disruption for the client. Cognitively impaired individuals often benefit from a quiet and calm environment, which would not be ensured in a room close to a potentially busy nursing station.
Choice D rationale:
A room with dim lighting can exacerbate confusion and disorientation in cognitively impaired individuals. Adequate lighting is essential for maintaining a safe and structured environment, as poor lighting can lead to falls and increased disorientation.
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