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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maintain a nonjudgmental attitude: A nonjudgmental approach promotes trust and encourages the client to disclose pertinent information.
B. Avoid mentioning alcohol use when collecting client data: It is essential to discuss alcohol use openly to guide effective care and intervention.
C. Offer sympathetic support: While empathy is important, over-sympathizing may undermine professional boundaries.
D. Verbalize disapproval of the substance abuse: Expressing disapproval is likely to provoke defensiveness and hinder communication.
Correct Answer is D
Explanation
A. "I have had bipolar disorder for over 10 years." While mental health conditions can co-occur with addiction, this statement does not directly indicate gambling addiction.
B. "My parents are my support system." This is a neutral statement and does not indicate addiction.
C. “I can't sleep at night. I have insomnia." Insomnia may occur for various reasons and is not diagnostic of gambling addiction.
D. "My wife left me. I lost my job and had to file for bankruptcy." Financial ruin and personal losses are strong indicators of gambling addiction.
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