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 C

Explanation

Choice A Reason:

Muscle spasms of the left leg can be uncomfortable and may require interventions such as muscle relaxants or repositioning of the limb, but they do not pose an immediate threat to the client's limb or life.

Choice B Reason:

One fingerbreadth of space between the cast and the skin is an important measurement to ensure that the cast is not too tight, but it does not represent an immediate threat to the client's circulation.

Choice C Reason:

Diminished pulses on the affected extremity. Diminished pulses on the affected extremity, in this case, the left leg with the long leg cast, is the most critical finding that requires immediate attention. It could indicate compromised blood flow, which is a medical emergency. Compromised blood flow can lead to tissue ischemia and necrosis if not promptly addressed.

Choice D Reason:

Ecchymosis (bruising) on the inner left thigh is concerning but may be related to the cast application or other factors. While it should be assessed and monitored, it is not as urgent as diminished pulses.

A. "You will have a leg bag to collect the urine." B. "You will feel pressure when I inflate the catheter balloon." C. "You cannot drink fluids for 4 hours after the procedure." D. "You will need to urinate before the procedure."

Correct Answer is D

Explanation

Choice A Reason:

Choice B Reason:

Inflating a catheter balloon is typically not part of intermittent catheterization, as it is more commonly associated with indwelling catheters.

Choice C Reason:

There is no need for the client to restrict fluid intake before or after intermittent catheterization. In fact, adequate hydration is generally encouraged.

Choice D Reason:

Intermittent catheterization involves inserting a catheter into the bladder to empty it completely, typically to measure residual urine. Before performing intermittent catheterization, it's essential for the client to try to urinate naturally to ensure that the bladder is as empty as possible. This step helps to provide accurate measurements of residual urine and reduces the risk of complications. Therefore, the nurse should include this information in the teaching to ensure the client understands the procedure's proper preparation. While the use of a leg bag to collect urine may be part of the overall management plan, it is not specific to the teaching about preparing for intermittent catheterization.

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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

A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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