A nurse is collecting data from a client who is receiving treatment for alcohol detoxification. Which of the following findings is the nurse's priority?

Hallucinations

Tremors

Anorexia

Insomnia

Answer and Explanation

The Correct Answer is A

A. Hallucinations. Hallucinations are a sign of severe alcohol withdrawal, such as delirium tremens (DTs), which can be life-threatening and requires immediate medical attention.

B. Tremors. Tremors are a common withdrawal symptom but are not as critical as hallucinations.

C. Anorexia. Loss of appetite is a minor symptom and not life-threatening.

D. Insomnia. Although common in withdrawal, insomnia is not an urgent priority compared to hallucinations.

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Correct Answer is C

Explanation

A. Increased irritability towards supervisors, outspokenness regarding work issues, increased attendance at staff meetings: These behaviors may reflect workplace dissatisfaction or burnout rather than substance use.

B. Crying, sharing personal details of relationship problems, monopolizing conversations: These are more indicative of emotional distress or poor boundaries, not necessarily substance use.

C. Volunteering for overtime on a continual basis, avoiding having a witness to wasting narcotics, needing to be alone in the medication room when preparing medications: These behaviors suggest potential access and misuse of medications, a key indicator of substance use disorder in healthcare workers.

D. Increased cheerfulness, increased energy, helping other nurses on the shift: While these behaviors might seem unusual, they are not strong indicators of substance use disorder.

A. "I will send you a note in a few weeks." B. "I know you will do well living out in the community." C. "Aren't you excited about being discharged today?" D. "How do you feel about being discharged?"

Correct Answer is D

Explanation

A. "I will send you a note in a few weeks.": This response is inappropriate and could blur professional boundaries in the therapeutic nurse-client relationship.

B. "I know you will do well living out in the community.": While supportive, this response assumes the client's future success without addressing their immediate feelings or concerns.

C. "Aren't you excited about being discharged today?": This response is leading and may not reflect the client’s true feelings.

D. "How do you feel about being discharged?": This open-ended question encourages the client to express their emotions and concerns about the transition, which is appropriate in the termination phase of the therapeutic relationship.

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A nurse is collecting data from a client who is receiving treatment for alcohol detoxification. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is reviewing a recent client report related to a staff nurse. Which of the following behaviors by a nurse at work might be red flags for a substance use disorder?

Correct Answer is C

Explanation

A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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