A nurse is caring for a client in the emergency department (ED).
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Alcohol withdrawal syndrome refers to the collection of symptoms that occur when individuals who are dependent on alcohol abruptly reduce or stop their alcohol intake.
Benzodiazepines, such as diazepam or lorazepam, are commonly used to manage symptoms such as anxiety, tremors, and seizures.
Providing a safe environment also ensures that the client does not involve in self-harming activities due to hallucinations.
Alcohol withdrawal syndrome is associated with an increased risk of seizures, particularly within the first 48 hours after cessation of alcohol consumption. Seizures can range from mild to severe and may be life-threatening if not promptly managed.
Chronic alcohol abuse can lead to dehydration and electrolyte imbalances due to increased urinary output, decreased fluid intake, and poor nutrition. Additionally, alcohol withdrawal itself can exacerbate fluid and electrolyte disturbances due to vomiting, diarrhea, diaphoresis, and increased metabolic demand.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Engaging in a conversation with the client allows the nurse to set clear expectations and boundaries. The nurse can explain the acceptable behavior and the consequences of disruptive actions. It’s essential to approach this conversation calmly and professionally.
B. While removing the client from social situations may temporarily prevent disruptive behavior, it does not address the underlying issue. Isolating the client may also negatively impact their well- being. It’s better to address the behavior directly rather than resorting to isolation.
C. Holding a community meeting involving all clients may not be appropriate or effective. It could escalate tensions and create an uncomfortable environment for everyone. Individualized interventions are more effective.
D. Ignoring disruptive behavior may not be the best approach. It’s essential to address the issue directly rather than expecting other clients to tolerate disruptive behavior.
Correct Answer is D
Explanation
D. Delusions are false beliefs that are firmly held despite evidence to the contrary. They are not based on reality and are often resistant to rational persuasion or evidence. Delusions can take various forms, such as persecutory (feeling targeted or spied on), grandiose (believing in exaggerated self-importance), or paranoid (feeling threatened or persecuted).
A. Hallucinations involve perceiving sensory experiences that are not present in reality. These sensory experiences can occur in any of the five senses, including seeing, hearing, tasting, smelling, or feeling things that are not actually there.
B. Anhedonia refers to the inability to experience pleasure or interest in activities that are typically enjoyable.
C. Illusions involve misinterpreting real sensory stimuli. Unlike hallucinations, which involve perceiving sensory experiences that are not present, illusions occur when existing sensory stimuli are misinterpreted or distorted.
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