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. Tardive dyskinesia (TD) is a movement disorder characterized by involuntary, repetitive movements of the face, tongue, lips, and extremities, often as a side effect of long-term use of antipsychotic medications such as fluphenazine. Valbenazine is a medication approved for the treatment of tardive dyskinesia in adults
A. Diphenhydramine is an antihistamine medication with anticholinergic properties used in acute dystonia
B Naloxone is an opioid antagonist used to reverse opioid overdose by blocking the effects of opioids on opioid receptors. It is not indicated for the treatment of tardive dyskinesia.
D. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant
Correct Answer is C
Explanation
C. This statement indicates an understanding of the needs of clients who are part of vulnerable populations because it demonstrates an awareness of the importance of client-centered care. Addressing the problem that the client believes is the most significant acknowledges the client's autonomy, respects their perspective, and ensures that their needs are prioritized.
A. This statement suggests a narrow focus on the immediate reason for the client's visit. While addressing the client's presenting concern is important, a limited assessment may overlook underlying issues or social determinants of health that could impact the client's well-being.
B. While privacy is important, asking clients for income or financial information may be necessary to assess their eligibility for financial assistance programs or to understand socioeconomic factors that may impact their health and access to care.
D. This statement suggests overlooking the importance of cultural competence in nursing practice. Cultural traditions, beliefs, and practices can significantly influence a client's health beliefs, behaviors, and preferences for care.
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