A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal.
The nurse should monitor the client for which of the following manifestations?
Hyperglycemia.
Decreased blood pressure.
Decreased heart rate.
Hyperthermia.
The Correct Answer is D
The correct answer is D. Hyperthermia.
Choice A reason: Hyperglycemia, which is an elevated blood glucose level, is not typically a direct manifestation of alcohol withdrawal. Alcohol withdrawal can sometimes lead to poor oral intake or vomiting, which might indirectly affect blood sugar levels, but hyperglycemia itself is not a primary concern in the context of alcohol withdrawal.
Choice B reason: Decreased blood pressure During alcohol withdrawal, the sympathetic nervous system is often overactive, leading to symptoms such as increased blood pressure, rather than decreased. Therefore, decreased blood pressure is not a common manifestation of alcohol withdrawal. Normal blood pressure ranges for adults are systolic BP of 100-120mmHg and diastolic BP of 70-80mmHg.
Choice C reason: Decreased heart rate Similar to blood pressure, the heart rate typically increases during alcohol withdrawal due to sympathetic nervous system overactivity. A normal resting heart rate for adults ranges from 60 to 100 beats per minute (bpm). Decreased heart rate is not expected during alcohol withdrawal.
Choice D reason: Hyperthermia, or elevated body temperature, is a common symptom of alcohol withdrawal. This occurs as part of the body’s response to the sudden absence of alcohol, and can be a part of the withdrawal syndrome, which includes a range of symptoms from mild anxiety to severe complications like seizures. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A client with bipolar disorder who is speaking loudly is displaying a manic symptom, which may require attention but is not the highest priority among the options. It does not pose an immediate risk to the client's physical health.
Choice B rationale:
A client with schizophrenia experiencing olfactory hallucinations may be distressed, but this is not an immediate physical health concern. It may require attention but is not the highest priority.
Choice D rationale:
Weight gain is a potential side effect of lithium, and while it should be monitored and addressed, it is not a critical finding that requires immediate attention.
Choice C rationale:
A client taking clozapine who reports a sore throat should be seen first. Clozapine is associated with a risk of agranulocytosis, a severe condition that can lead to a dangerously low white blood cell count. A sore throat can be an early sign of infection, and in the context of clozapine use, it is crucial to assess and monitor for agranulocytosis promptly. This condition is life-threatening and requires immediate attention to prevent complications. .
Correct Answer is D
Explanation
Choice A rationale:
Hemoglobin levels at 16 g/dL are within the normal range for an adult, so there is no need to report this result to the provider.
Choice B rationale:
A white blood cell (WBC) count of 8,000/mm3 is within the normal range, and there is no need to report this result to the provider.
Choice C rationale:
An RBC count of 4.9 million/mm² is within the normal range for adults, so it does not require reporting to the provider.
Choice D rationale:
A platelet count of 100,000/mm3 is below the normal range (typically 150,000-450,000/mm3). This lower platelet count can increase the risk of bleeding and may be associated with clonazepam use. Therefore, it should be reported to the provider for further evaluation and potential adjustment of the medication.
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