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 A
Explanation
A. Neonatal abstinence syndrome (NAS) occurs in newborns who have been exposed to opioids or other addictive substances while in the womb, typically due to maternal substance use during pregnancy.
B. The term "substance use disorder" typically refers to the condition in the person who is using the substance, rather than the manifestations experienced by the newborn.
C. Fetal alcohol syndrome (FAS) occurs in infants born to mothers who consumed alcohol during pregnancy. It is characterized by a range of physical, cognitive, and behavioral abnormalities, including growth deficiencies, facial abnormalities, and intellectual disabilities.
D. Tolerance refers to the body's decreased response to a substance due to repeated exposure. While tolerance can develop in both the mother and the fetus when opioids are used during pregnancy, the manifestations observed in the newborn, such as irritability, tremors, and feeding difficulties, are not indicative of tolerance.
Correct Answer is B
Explanation
B. Social determinants of health are the conditions in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life. These determinants include factors such as socioeconomic status, education, employment, housing, and access to healthcare.
A. Health equity refers to the absence of disparities in health and healthcare among different populations. However, this option does not specifically address the client's situation of unemployment and homelessness.
C. Treatment protocols are important for guiding clinical practice but they do not directly address the social determinants of health impacting the client's situation.
D. Unconscious bias refers to implicit attitudes or stereotypes that influence judgments and behaviors in a subconscious manner but do not directly address the social determinants of health impacting the client's situation of unemployment and homelessness.
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