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 C
Explanation
C. It acknowledges the client's request and communicates that their request will be addressed in collaboration with their healthcare provider. This response respects the client's autonomy while also ensuring that medication decisions are made within the context of a comprehensive healthcare plan overseen by a qualified provider.
A. This statement may come across as dismissive or confrontational to the client. It does not effectively address the client's request or provide guidance on how to proceed.
B. This question may imply suspicion or judgment about the client's motives for seeking a new prescription. It does not foster open communication or collaboration between the nurse and the client and may create a barrier to effective communication.
D. This option is not the appropriate response to a request for a new medication prescription. This option does not address the client's specific request and may not be relevant to their current healthcare needs.
Correct Answer is C
Explanation
C. Codependency refers to a dysfunctional pattern of behavior in which a person excessively relies on another individual (often a partner or family member) for their sense of identity, self- worth, or emotional well-being. In this scenario, the partner's demand to see the client's records
and treatment plan, as well as the assertion of needing to oversee the treatment, suggests an excessive need for control and involvement in the client's life and healthcare decisions.
A. Manipulation involves influencing or controlling someone in a deceptive or dishonest way to achieve one's own goals.
B. Marginalization refers to the exclusion or relegation of a person or group to a lower or outer edge of society or a group.
D. Enabling refers to behaviors that unintentionally or intentionally allow someone to continue engaging in harmful behaviors or avoid facing consequences.
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