A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).
Tachycardia.
Tremors.
Hallucinations.
Hypotension.
Seizures.
Correct Answer : A,B,C,E
Choice A rationale:
Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.
Choice B rationale:
Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.
Choice C rationale:
Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.
Choice E rationale:
Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.
Choice D rationale:
Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges
Choice A rationale:
Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.
Choice B rationale:
Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.
Choice C rationale:
Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.
Choice D rationale:
Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.
Choice E rationale:
Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.
Correct Answer is D
Explanation
Choice A rationale:
Administering medication to sedate the client is not the appropriate initial action. The client's confusion and restlessness could be due to various factors, and administering sedative medication without identifying the cause of these symptoms could lead to adverse effects or mask underlying issues.
Choice B rationale:
Calling the family to stay with the client might provide emotional support, but it doesn't directly address the client's safety needs. The client's increasing confusion and restlessness require a more immediate intervention to ensure their safety.
Choice C rationale:
Applying wrist and leg restraints should be a last resort and is not the appropriate initial action in this situation. Restraints should only be used if less restrictive interventions have failed and the client's safety is at risk. Restraints can lead to complications such as decreased mobility, skin breakdown, and increased agitation.
Choice D rationale:
Correct Choice Moving the client to a room closer to the nurses' station is the most appropriate action in this scenario. This intervention helps to increase the client's visibility and proximity to nursing staff, making it easier to monitor and address their needs promptly. It also promotes a safer environment while allowing the healthcare team to assess the underlying causes of the restlessness and confusion.
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