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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

The correct answer is: A, B, C, D.

Choice A reason: Shortening a reading activity when the child appears to become frustrated can help prevent the child from becoming overwhelmed and acting out. This is a common strategy used in managing children with conduct disorders.

Choice B reason: Introducing humor during interactions with the child can help build rapport and make the child feel more comfortable. It can also serve as a positive distraction and reduce tension.

Choice C reason: Redirecting with physical activities when the child’s disruptive behavior begins can serve as a healthy outlet for the child’s energy and frustrations. Physical activities can also help improve the child’s mood and reduce disruptive behaviors.

Choice D reason: Explaining to the child the importance of picking up crayons when thrown on the floor can help teach the child responsibility and respect for their environment. This can also be a part of behavioral therapy where the child learns about consequences of their actions.

Choice E reason: Placing the child in a vest restraint when disruptive behavior occurs is not recommended. Using physical restraints can be traumatizing and should only be used as a last resort when the child’s behavior poses a risk to themselves or others. It’s always better to use de-escalation techniques and positive reinforcement to manage disruptive behavior.

A. Use clarification to determine what the patient is feeling. B. Never break constant eye contact with the patient. C. Move the patient to a private area so the conversation will not be disturbed and cannot be seen. D. Speak to the patient using an authoritative voice and ask them, "Why are you acting this way?”

Correct Answer is A

Explanation

Choice A rationale:

When dealing with an angry and aggressive client, using clarification is an essential communication technique. It involves asking open-ended questions to better understand the patient's emotions and concerns, which can help defuse the situation and provide insight into the underlying issues.

Choice B rationale:

Maintaining constant eye contact can be interpreted as confrontational or aggressive behavior, potentially escalating the client's aggression. It's important to maintain a respectful distance and avoid behaviors that could exacerbate the situation.

Choice C rationale:

Moving the patient to a private area is a reasonable approach if the environment is contributing to the patient's agitation. However, the primary concern should be the safety of both the patient and the staff. Privacy can be important, but it shouldn't compromise safety.

Choice D rationale:

Speaking to the patient with an authoritative voice and asking "why" questions can escalate the situation further. It may come across as confrontational and provoke a defensive reaction from the patient. Open-ended questions that encourage the patient to express their feelings can be more effective in de-escalation.

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A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

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