A nurse is caring for a client who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdraw which of the following conditions should the nurse identify as causing these manifestations?

Autonomic dysreflexia

Synergistic effect

Sleep deprivation

Delirium

Answer and Explanation

The Correct Answer is D

A. Autonomic dysreflexia: This condition typically occurs in individuals with spinal cord injuries above the T6 level and presents with sudden, severe hypertension, bradycardia, headache, and profuse sweating. It is not typically associated with alcohol withdrawal symptoms such as visual hallucinations and impaired consciousness.

B. Synergistic effect: This term refers to the combined effect of two or more substances or factors being greater than the sum of their individual effects. While alcohol withdrawal can interact with other substances or conditions to produce various effects, it is not a specific condition causing visual hallucinations and impaired consciousness.

C. Sleep deprivation: Prolonged sleep deprivation can lead to cognitive impairment, mood disturbances, and hallucinations, but it is not typically associated with impaired consciousness as described in the scenario. Additionally, the manifestations described are more indicative of alcohol withdrawal rather than sleep deprivation alone.

D. Delirium: Delirium is a state of acute confusion and altered consciousness characterized by disturbances in attention, awareness, cognition, and perception. Visual hallucinations and impaired consciousness are common features of delirium, especially in the context of alcohol withdrawal. Delirium often occurs due to underlying medical conditions, substance withdrawal, or medication side effects.

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Correct Answer is D

Explanation

A. The client states that he has developed sudden hearing loss: This could potentially be an example of somatization, where psychological distress is expressed through physical symptoms. However, sudden hearing loss alone might not specifically indicate regression.

B. The client states that his partner will not visit because they are too busy with their job: This statement does not directly suggest regression. It appears to be an explanation or justification for the partner's behavior.

C. The client yells obscenities at the nurse: Yelling obscenities could indicate frustration or anger, but it does not necessarily suggest regression. It could be a response to the current situation rather than a regressive behavior.

D. The client stomps his feet and throws objects off the bedside table: This behavior could indicate regression. Stomping feet and throwing objects are more characteristic of childish or immature behavior, which suggests a regression to an earlier stage of emotional development.

A. “I can hear him crying in the middle of the night.” B. "He spends most of his time locked in his room.” C. “He refuses to go to the movies with his friends.” D. “I noticed several cutting marks on both of his arms.”

Correct Answer is D

Explanation

A. “I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

B. "He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

C. “He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

D. “I noticed several cutting marks on both of his arms.”: This statement is the most concerning and indicates a potential self-harm behavior. Self-harm, such as cutting, can be a significant risk factor for suicide, especially if the behavior escalates or if the individual expresses suicidal thoughts or intentions.

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A nurse is caring for a client who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdraw which of the following conditions should the nurse identify as causing these manifestations?

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Correct Answer is D

Explanation

A nurse in a well-child clinic receives a phone call from the parent of an adolescent client. The parent states. "I think my son might try to kill himself." Which of the following statements by the parent is the priority for the nurse to investigate further?

Correct Answer is D

Explanation

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