A nurse is discussing the possible physical effects of alcohol withdrawal with a newly licensed nurse.
Which of the following effects should the nurse include? (Select all that apply.)

Seizures

Nystagmus

Tremors

Hallucinations

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale:

Seizures are a potentially serious complication of alcohol withdrawal. They occur due to the sudden decrease in GABA (gamma-aminobutyric acid), a neurotransmitter that has inhibitory effects on the central nervous system. Chronic alcohol consumption leads to an upregulation of GABA receptors in the brain to compensate for the depressant effects of alcohol. When alcohol is abruptly withdrawn, the brain is left in a hyperexcitable state, as there is less GABA to suppress neuronal activity. This hyperexcitability can manifest as seizures.

Mechanism of seizures in alcohol withdrawal:

Neuroadaptation: Chronic alcohol exposure leads to adaptations in neuronal excitability to counteract the depressant effects of alcohol. These adaptations include:

Upregulation of GABA receptors: The brain increases the number of GABA receptors to enhance the inhibitory effects of GABA.

Downregulation of glutamate receptors: The brain decreases the number of glutamate receptors to reduce the excitatory effects of glutamate.

GABA rebound: When alcohol is abruptly withdrawn, the upregulated GABA receptors become hypersensitive, leading to an excessive inhibitory response. This is known as GABA rebound.

Glutamate rebound: Concurrently, the downregulated glutamate receptors become more sensitive, leading to an enhanced excitatory response. This is known as glutamate rebound.

Imbalance: The combination of GABA rebound (excessive inhibition) and glutamate rebound (excessive excitation) creates a state of neuronal hyperexcitability, which can trigger seizures.

Risk factors for seizures in alcohol withdrawal:

Severity of alcohol dependence: Individuals with a long history of heavy alcohol consumption are at higher risk.

Previous alcohol withdrawal seizures: A history of seizures during past withdrawal episodes increases the likelihood of recurrence.

Comorbid medical conditions: Certain medical conditions, such as electrolyte imbalances, head injuries, or infections, can increase the risk of seizures.

Concurrent medication use: Certain medications, such as benzodiazepines or barbiturates, can lower the seizure threshold.

Management of seizures in alcohol withdrawal:

Benzodiazepines: Benzodiazepines are the mainstay of treatment for alcohol withdrawal seizures. They enhance the effects of GABA, helping to suppress neuronal excitability and prevent seizures.

Anticonvulsants: In some cases, anticonvulsants, such as gabapentin or valproate, may be used in addition to benzodiazepines.

Electrolyte replacement: Electrolyte imbalances, such as hyponatremia or hypomagnesemia, can contribute to seizures and should be corrected.

Monitoring: Close monitoring of vital signs, neurological status, and seizure activity is essential to ensure prompt intervention if seizures occur.

Choice B rationale:

Nystagmus, or involuntary eye movements, is not a common symptom of alcohol withdrawal. While it can occur in some cases, it is not considered a primary feature of the syndrome.

Choice C rationale:

Tremors are a very common symptom of alcohol withdrawal. They are caused by the same underlying mechanism as seizures, namely, the hyperexcitability of the central nervous system due to decreased GABA activity. Tremors typically manifest as shaking hands, arms, or legs, and can range in severity from mild to severe.

Choice D rationale:

Hallucinations, both auditory and visual, can occur in alcohol withdrawal. They are thought to be due to a combination of factors, including the hyperexcitability of the central nervous system, disruptions in neurotransmitter systems, and sleep deprivation. Hallucinations can be very distressing and can lead to agitation, confusion, and disorientation.

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Correct Answer is B

Explanation

Choice A rationale:

While group activities can be beneficial for some clients with bipolar disorder, they may not be appropriate during a manic phase. This is because group settings can be overstimulating and overwhelming for individuals experiencing mania. The increased activity and social interaction can exacerbate symptoms such as racing thoughts, pressured speech, and impulsivity.

It's crucial to prioritize calming activities and minimize external stimuli during manic episodes.

Choice C rationale:

Providing a stimulating environment is not recommended for clients in the manic phase of bipolar disorder. A stimulating environment can worsen symptoms of mania, such as:

Increased energy and activity levels

Racing thoughts

Impulsivity

Distractibility

Risk-taking behavior

Irritability

Aggression

Decreased need for sleep Grandiose thinking

Poor judgment

Hypersexuality

A calm and structured environment is more conducive to managing manic symptoms.

Choice D rationale:

Scheduling daily seclusion times is not a standard intervention for clients in the manic phase of bipolar disorder. Seclusion is a restrictive intervention that should only be used as a last resort when a client is at risk of harming themselves or others. It's essential to explore less restrictive alternatives for managing manic symptoms, such as medication, therapy, and environmental modifications.

A. “I will increase my water intake up to 8 glasses a day.” B. “I may experience sedation and sleepiness.” C. “I will notice an improvement in my sex drive.” D. “I should expect to feel better within 3 to 4 days.”

Correct Answer is B

Explanation

Choice A rationale:

Increased water intake is not a specific teaching point for fluoxetine. While general hydration is important for overall health, it's not directly related to the medication's effectiveness or side effects.

Fluoxetine is not known to cause dehydration or require fluid intake beyond typical recommendations.

Focusing on water intake could potentially distract from more relevant education about the medication.

Choice B rationale:

Sedation and sleepiness are common side effects of fluoxetine, especially during the initial weeks of treatment.

It's important for the client to be aware of these potential side effects so they can make necessary adjustments to their activities, such as avoiding driving or operating machinery if drowsy.

Understanding that these side effects are expected can also help with adherence to treatment, as clients may be less likely to discontinue the medication if they know that the side effects are likely to subside over time.

Choice C rationale:

Fluoxetine can sometimes cause sexual side effects, such as decreased libido or difficulty achieving orgasm.

It's important for the client to be aware of this potential side effect, but it's not accurate to say that they will definitely notice an improvement in their sex drive.

Sexual side effects can be distressing and may impact treatment adherence, so open communication with the healthcare provider is essential if these issues arise.

Choice D rationale:

Fluoxetine can take several weeks, typically 4-6 weeks, to fully exert its therapeutic effects.

Expecting to feel better within 3-4 days could lead to disappointment and frustration if symptom improvement isn't immediately noticeable.

It's important for the client to understand that patience is needed while the medication takes effect.

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A nurse is discussing the possible physical effects of alcohol withdrawal with a newly licensed nurse. Which of the following effects should the nurse include? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse recommend to include?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has a history of depression about a new prescription for fluoxetine. Which statement by the client indicates understanding of the teaching?

Correct Answer is B

Explanation

Medical History: The patient is on Naltrexone 50mg PO once daily and Fluoxetine 20mg PO every morning. The nurse has reviewed the client’s electronic health record. Which of the following client findings require immediate follow-up by the nurse? (Select all that apply.)

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A nurse is caring for a client who has schizophrenia and notices changes in the client’s behavior. Which of the following behaviors is the nurse’s priority to report to the provider?

A nurse is attending to a client experiencing acute anxiety. Which of the following actions should the nurse undertake? (Select all that apply.)

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse’s priority?

A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?

A nurse is discussing the possible physical effects of alcohol withdrawal with a newly licensed nurse.
Which of the following effects should the nurse include? (Select all that apply.)