A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

Hypertension

Constipation

Polyuria

Bradycardia

Answer and Explanation

The Correct Answer is A

Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.

Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.

Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.

Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.

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Correct Answer is D

Explanation

Choice A Reason:

Restraining the child's upper extremities is not recommended. It's important to allow the child to move freely during the seizure to prevent injury. Attempting to restrain their movements could result in harm to the child or the person attempting to restrain them.

Choice B Reason:

Turning the child onto their back is generally appropriate as long as you do it gently and without force. It helps ensure that the airway remains clear and allows any fluids to drain out of the mouth. However, you should not forcibly turn the child; instead, gently guide them if necessary.

Choice C Reason:

Placing a padded tongue blade or any object in the child's mouth is strongly discouraged during a seizure. Doing so can result in injury to the child's mouth, teeth, or jaw. It is a common misconception that someone might swallow their tongue during a seizure, but this rarely happens. It's essential to keep the child's airway clear but not to insert any objects into their mouth.

D. Placing a pillow under the child's head is appropriate to protect their head from injury, especially if they are on a hard surface. It can help cushion the head and reduce the risk of head trauma during the seizure.

A. Posterior fontanel closed B. Anterior fontanel closed C. Plays with toes D. Moves objects to mouth

Correct Answer is B

Explanation

Choice A Reason:

Posterior fontanel closed is incorrect, it is normal for the posterior fontanel to close earlier than the anterior fontanel, usually by 2 to 3 months of age.

Choice B Reason:

Anterior fontanel closed is correct. The anterior fontanel is the soft spot on the top of a baby's head, and it typically closes between 12 to 18 months of age. If the anterior fontanel is closed in a 4-month-old infant, it is considered an early closure, which can be a cause for concern. Early closure of the anterior fontanel can be associated with various underlying medical conditions, such as craniosynostosis (premature fusion of the skull bones) or dehydration.

Choice C Reason:

Plays with toes is incorrect. At 4 months of age, infants are typically developing their motor skills, and playing with their toes is a sign of normal development.

Choice D Reason:

Moves objects to mouth is incorrect. At this age, infants often explore their environment by bringing objects to their mouths as part of their sensory exploration and development.

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A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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