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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
"Who do you talk to when you are upset?" explores the client's social support system, which is a critical component of their psychosocial status. Social support can buffer stress, provide emotional comfort, and contribute to overall well-being. Understanding who the client relies on for support helps assess their coping mechanisms and social connectedness.
Choice B rationale
"Do you have medical insurance?" pertains to the client's access to healthcare resources and socioeconomic status. While these factors can influence overall well-being, they are not direct indicators of the client's psychosocial status, which focuses more on their mental, emotional, and social functioning.
Choice C rationale
"When did you last have a mammogram?" is a question related to the client's physical health and preventive care practices, specifically relevant for female clients. It does not directly assess their psychosocial status, which encompasses their emotional state, social interactions, and coping abilities.
Choice D rationale
"How old were you when you started your menses?" is a question about the client's sexual and reproductive health history, relevant for female clients. While significant life events can indirectly impact psychosocial well-being, this specific question does not directly assess their current emotional state, social relationships, or coping mechanisms.
Correct Answer is B
Explanation
Choice A rationale
Directly contradicting the client's hallucination by stating "I'm using a syringe to obtain your blood, not a snake" dismisses their experience and does not address their fear or distress. This can erode trust and make the client feel unheard.
Choice B rationale
Acknowledging the client's perception ("I don't see a snake") while validating their feelings ("that must be scary for you") is a therapeutic response. It shows empathy and helps the client feel understood without confirming the hallucination as real.
Choice C rationale
Telling the client "You must be mistaken. Snakes cannot be in the clinic" is dismissive and invalidates their sensory experience. Hallucinations are real to the person experiencing them, and denying their reality can be counterproductive.
Choice D rationale
Stating "Your provider requires this blood specimen" provides a factual explanation for the procedure but does not address the client's immediate fear and anxiety related to the hallucination. It prioritizes the task over the client's emotional state. .
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