A nurse is caring for a client who has alcohol use disorder.
Which of the following findings should indicate to the nurse that the client is experiencing the initial stage of acute withdrawal?

Depression.

Delusions.

Tremors.

Bradycardia.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Depression is a mood disorder characterized by persistent sadness, loss of interest, and feelings of hopelessness. While it can co-occur with alcohol use disorder, it is not typically the initial manifestation of acute alcohol withdrawal. Acute withdrawal primarily involves physiological and neurological symptoms resulting from the abrupt cessation of alcohol consumption.

Choice B rationale

Delusions are fixed false beliefs that are not based in reality. These are more characteristic of severe alcohol withdrawal, such as delirium tremens, or other psychotic disorders, rather than the initial stage of acute withdrawal. The initial stage is typically marked by milder symptoms related to central nervous system hyperactivity.

Choice C rationale

Tremors, particularly hand tremors, are a common and characteristic early sign of acute alcohol withdrawal. Alcohol has a depressant effect on the central nervous system. When alcohol consumption is stopped, the central nervous system rebounds, leading to increased neuronal excitability. This hyperactivity manifests as tremors, along with other symptoms like anxiety and increased heart rate.

Choice D rationale

Bradycardia, a heart rate below 60 beats per minute, is not a typical finding in the initial stage of acute alcohol withdrawal. Instead, the sympathetic nervous system activation that occurs during withdrawal usually leads to tachycardia (an elevated heart rate) and hypertension as the body attempts to compensate for the absence of alcohol's depressant effects.

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Correct Answer is C

Explanation

Choice A rationale

Encouraging the client to nap during the day might disrupt their sleep-wake cycle further, potentially increasing nighttime wandering. Daytime napping can reduce the need for nighttime sleep in individuals with Alzheimer's disease.

Choice B rationale

Administering an antianxiety medication before bedtime may sedate the client but does not address the underlying cause of the nighttime wandering and can have side effects, including increased confusion and risk of falls in older adults.

Choice C rationale

Placing a lock at the top of doors leading outside is a crucial safety measure for clients with Alzheimer's disease who wander at night. This prevents them from leaving the home unsupervised and potentially getting lost or injured.

Choice D rationale

Using light restraints while the client is in bed is generally not recommended and should be a last resort due to ethical and safety concerns. Restraints can increase agitation and anxiety and may cause physical harm.

A. Keep the client's room dark at night. B. Limit the client's need to make decisions. C. Discourage visitation from the client's family. D. Provide a consistent daily routine.

Correct Answer is D

Explanation

Choice A rationale

Keeping the client's room dark at night can worsen delirium by reducing environmental cues and potentially increasing disorientation and fear. Clients with delirium benefit from a well-lit environment that helps them maintain a sense of reality and reduces the risk of misinterpreting stimuli.

Choice B rationale

Limiting the client's need to make decisions can decrease their sense of control and autonomy, potentially increasing agitation and frustration associated with delirium. While simplifying choices is helpful, completely eliminating decision-making can be counterproductive to their engagement and orientation.

Choice C rationale

Discouraging visitation from the client's family can increase the client's feelings of isolation and anxiety, which can exacerbate delirium. Familiar faces and voices can provide comfort and reassurance, aiding in orientation and reducing agitation.

Choice D rationale

Providing a consistent daily routine helps to orient the client with acute delirium to time and place, reducing confusion and anxiety. Predictable patterns of activity, such as meals, hygiene, and rest, offer structure and familiarity, which can stabilize cognitive function and promote a sense of security.

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A nurse is caring for a client who has alcohol use disorder.Which of the following findings should indicate to the nurse that the client is experiencing the initial stage of acute withdrawal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who has alcohol use disorder.
Which of the following findings should indicate to the nurse that the client is experiencing the initial stage of acute withdrawal?