A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?
Stage 1 (mild)
Stage 3 (severe)
The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal.
Stage 2 (moderate)
The Correct Answer is B
Stage 3 alcohol withdrawal, also known as delirium tremens (DTs), is characterized by severe manifestations, including hallucinations (such as seeing spiders crawling on the walls), disorientation, agitation, and potentially life-threatening physiological disturbances. The client's
belief that they are at home and calling for their mother indicates significant confusion and disorientation, which are common features of delirium tremens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Schizophrenia is typically diagnosed in young adulthood, usually in the late teens to early twenties, although it can also occur later in life. Symptoms often emerge during this period of development, characterized by disturbances in thinking, perception, emotions, and behavior.
Correct Answer is D
Explanation
D. Serotonin syndrome is a potentially life-threatening condition that can occur when there is an excess of serotonin in the body. Certain herbal remedies, such as St. John's Wort, can increase serotonin levels and may lead to serotonin syndrome, particularly when used in combination with prescription medications that also affect serotonin levels, such as selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors (MAOIs).
A. It's important for the nurse to provide accurate and balanced information about the potential benefits and limitations of herbal remedies, rather than dismissing them outright.
B. Simply discouraging the use of herbal remedies without addressing the client's concerns or providing information about potential risks may not be effective or conducive to open communication.
C. Many herbal remedies can interact with prescription medications, altering their effectiveness or increasing the risk of adverse effects
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