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 D
Explanation
Choice A rationale:
Periods of elation with unusual talkativeness. Rationale: While periods of elation with unusual talkativeness can be associated with certain mental health conditions, such as bipolar disorder, they are not specific to schizophrenia. These symptoms are more indicative of mania, which is characteristic of bipolar disorder.
Choice B rationale:
Recurrent thoughts of past trauma. Rationale: Recurrent thoughts of past trauma can be associated with various mental health disorders, including post-traumatic stress disorder (PTSD), but they are not specific to schizophrenia. Schizophrenia is primarily characterized by disturbances in thought processes, perception, and behavior.
Choice C rationale:
Preoccupied with folding clothes. Rationale: Preoccupation with folding clothes is not a hallmark symptom of schizophrenia. Schizophrenia is characterized by symptoms such as hallucinations, delusions, disorganized thinking, and impaired social functioning.
Choice D rationale:
Invents words that have no meaning. Rationale: This statement is correct. Inventing words that have no meaning, also known as "neologisms," is a symptom often observed in individuals with schizophrenia. Neologisms are a manifestation of disorganized thinking and communication.
Correct Answer is C
Explanation
Choice A rationale:
The Brief Patient Health naire (Brief PHQ) is primarily used for assessing the presence and severity of depressive symptoms and not specifically for cognitive disorders. It consists of nine items that assess the frequency of specific symptoms over the past two weeks.
Choice B rationale:
The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and other related psychotic disorders. It includes items related to affective blunting, alogia, anhedonia, and avolition, which are not directly relevant to the assessment of cognitive disorders.
Choice C rationale:
The Mental Status Examination (MSE) is a comprehensive assessment of cognitive function, including orientation, memory, attention, language, and executive function. It provides valuable information about the client's cognitive abilities and can aid in diagnosing cognitive disorders such as dementia or delirium.
Choice D rationale:
The Abnormal Involuntary Movements Scale (AIMS) is used to assess the presence and severity of tardive dyskinesia, a movement disorder commonly associated with the use of antipsychotic medications. It is not relevant to the assessment of cognitive disorders.
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