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 ["A","B","D"]

Explanation

A. Grandiosity: Individuals experiencing a manic episode may exhibit grandiosity, such as an inflated sense of self-importance, superiority, or power.

B. Flight of ideas: Flight of ideas refers to rapid, continuous speech that jumps from one topic to another, often with loose associations. It is a common manifestation of a manic episode.

C. Splitting: Splitting is a defense mechanism commonly associated with certain personality disorders, such as borderline personality disorder, but it is not typically observed during a manic episode of bipolar disorder.

D. Hyperactivity: Hyperactivity, or increased physical activity, is characteristic of a manic episode. Clients may engage in excessive goal-directed activities or restlessness.

E. Withdrawal: Withdrawal, or social withdrawal, is not a typical behavior during a manic episode. Instead, individuals with mania tend to exhibit increased sociability and extroversion.

A. Initiate one-to-one observation. B. Encourage the client to participate in group activities C. Administer an antidepressant D. Set up a time for individual meetings with the client

Correct Answer is A

Explanation

A. Initiate one-to-one observation: This intervention involves assigning a staff member to directly observe and monitor the client continuously. It is crucial in ensuring the client's safety, particularly after a suicide attempt, as it helps prevent further harm or self-injury. Therefore, initiating one-to-one observation is the priority intervention.

B. Encourage the client to participate in group activities: Group activities may be beneficial for the client's overall well-being and recovery, but they are not the priority immediately after a suicide attempt. Safety and stabilization take precedence.

C. Administer an antidepressant: While antidepressant medication is an essential component of treatment for major depressive disorder, initiating medication is not the priority at this moment. The client's safety and stabilization should be addressed first before starting pharmacological treatment.

D. Set up a time for individual meetings with the client: Individual meetings and therapeutic interventions are important for addressing the client's mental health needs, but they are not the priority immediately after a suicide attempt. Safety measures should be implemented first.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is A

Explanation

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