A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestation should the nurse include in the reaching? (Select all that apply.)
Nystagmus
Illusions
Polyphagia
Tremors
Seizures
Correct Answer : B,D,E
A. Nystagmus: Nystagmus is not a typical manifestation of alcohol withdrawal. It is more commonly associated with intoxication or neurological conditions. Therefore, it is not included in the effects of alcohol withdrawal.
B. Illusions: Illusions (misinterpretations of external stimuli) are common during alcohol withdrawal, especially in severe cases such as withdrawal delirium (delirium tremens). Clients may misinterpret shadows or objects as threatening.
C. Polyphagia: Polyphagia (excessive eating) is not a recognized manifestation of alcohol withdrawal. Clients with withdrawal may experience nausea or a lack of appetite rather than an increased appetite.
D. Tremors: Tremors, often called "the shakes," are one of the most common early signs of alcohol withdrawal. They usually begin within hours after alcohol cessation.
E. Seizures: Seizures, specifically generalized tonic-clonic seizures, are a serious complication of alcohol withdrawal. They can occur within 6–48 hours after the last drink and are part of alcohol withdrawal syndrome.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client has begun playing basketball with several other clients during the past month.
Engaging in activities and social interactions can actually be a positive sign, as it suggests involvement and connection with others, which can be protective against suicide.
B. The client identifies with problems expressed by other clients.
Identifying with others' problems may indicate empathy, but it is not necessarily indicative of suicide risk on its own.
C. The client's behavior has become impulsive in the past few weeks.
Explanation: Impulsivity can be a significant risk factor for suicide. A sudden increase in impulsive behavior might indicate that the client is not thinking clearly and is acting without considering the potential consequences. Impulsivity can lead to actions that are harmful or dangerous, including suicidal behaviors.
D. The client states she wants to go home to be with her children and partner.
Expressing a desire to be with loved ones is generally not an indicator of suicide risk. In fact, having a strong support system can be protective against suicidal thoughts.
Correct Answer is C
Explanation
A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.
B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.
C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.
D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.
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