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)

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

C Encouraging the client to identify the emotions they feel immediately before performing the self-harm behavior is an important intervention. It can help the client develop insight into triggers and underlying emotions that contribute to the behavior. Identifying and addressing these emotions can be a crucial step in developing healthier coping mechanisms.

A. It is crucial to convey the potential risks associated with self-harm and emphasize the importance of seeking help and safer coping strategies.

B. Non-suicidal self-harm is a significant concern that requires attention and appropriate intervention. While NSSH does not necessarily indicate immediate suicidal intent, it can indicate significant distress

D. NSSH does not necessarily indicate suicidal intent, and placing the client in constant observation without clinical justification may be intrusive and undermine therapeutic rapport.

A. Hamburgers B. Cheese pizza C. Tuna sandwich D. Turkey sandwich

Correct Answer is C

Explanation

A. Diets high in saturated fats like hamburgers have been associated with an increased risk of cognitive decline and Alzheimer's disease progression.

B. Cheese pizza, like hamburgers, is often high in saturated fats and may not be the best choice for promoting brain health.

C. Omega-3 fatty acids are considered essential nutrients that may help reduce inflammation and support brain cell function. This combined actions improves memory

D.Turkey is a good source of protein but is not as beneficial in Dementia .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is providing dietary teaching to a client who has been diagnosed with Alzheimer's disease about including foods to decrease the progression of the disease. Which of the following foods should the nurse recommend?

Correct Answer is C

Explanation

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices. I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make?

A nurse is observing a group therapy session. Which of the following client statements should the nurse identify as an indication of bulimia nervosa?

A nurse is caring for a client who is experiencing periods of hyperactivity, impulsivity, and inattentiveness. Which of the following medications should the nurse anticipate the provider to prescribe?

A nurse is presenting information about the prevention of sexually transmitted infections to a group of high school students. The nurse should identify that this is an example of which of the following types of prevention?

A community health nurse is conducting a presentation about modifiable risk factors at a local community center. A community member asks a question and the nurse does not know the answer. Which of the following actions should the nurse take?

A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client?

A nurse is caring for a client who describes extreme fear of having or acquiring a disease. The client is also exhibiting behaviors like repeated body checking. The nurse should identify that the client is exhibiting manifestations of which of the following disorders?