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
A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role of monopolizer? The correct answer is choice C. The adolescent daughter who attempts to dominate the discussion.
Choice A rationale:
The father who intervenes whenever the siblings argue does not necessarily fit the role of a monopolizer. While his intervention may affect the dynamics, it may not be an attempt to monopolize the discussion. His actions could be aimed at conflict resolution.
Choice B rationale:
The mother who expresses hostility toward her spouse also does not fit the role of a monopolizer. Expressing hostility is a different issue and does not necessarily mean she's monopolizing the discussion.
Choice C rationale:
The adolescent daughter who attempts to dominate the discussion is likely acting as the monopolizer. In family dynamics, a monopolizer is someone who seeks to control and dominate the conversation, often not allowing others to express their thoughts or opinions. This behavior can disrupt effective communication within the family.
Choice D rationale:
The adolescent son who refuses to share personal feelings is not acting as a monopolizer. While his behavior may affect communication, it is different from actively dominating the discussion.
Correct Answer is B
Explanation
Choice A rationale:
Requesting that the provider renew the prescription for restraints every 8 hours is not the best approach. The nurse should follow the facility's policies and protocols for the use of restraints, and these policies typically require that the provider assess the client within a specific timeframe after applying restraints. The provider's assessment should occur promptly to determine the client's continued need for restraints and to address the client's safety and well-being.
Choice C rationale:
Evaluating the client hourly while the restraints are applied is not sufficient. While it's important to monitor the client, especially in terms of circulation and comfort, the provider's assessment should take place within a shorter timeframe, typically within one hour after applying the restraints. Hourly evaluations alone may not be timely enough to address the client's condition and the necessity of the restraints.
Choice D rationale:
Obtaining a prescription for restraints on an as-needed basis is not an appropriate approach. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a specific assessment by the provider. Using restraints on an as-needed basis without a clear prescription can lead to ethical and legal issues and should be avoided.
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