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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Approaching the client frequently throughout the day for brief interactions might exacerbate the client's suspiciousness and discomfort. Individuals who are extremely suspicious may interpret frequent approaches as intrusive or manipulative, leading to increased agitation or withdrawal.

Choice B rationale:

Disclosing personal information to the client in an attempt to demonstrate approachability is not recommended. Sharing personal information can blur professional boundaries and may not necessarily address the client's suspicion. It's important to build trust gradually through consistent, respectful, and professional interactions.

Choice C rationale:

Adopting a neutral attitude when providing care is appropriate because it helps create a non-threatening environment. Individuals who are suspicious may interpret overly friendly or emotionally charged behavior as insincere or manipulative. A neutral and respectful approach allows the client to feel more comfortable and safe in the nurse's presence.

Choice D rationale:

Waiting for the client to initiate interaction may not be effective in establishing a therapeutic relationship. Extremely suspicious clients might be hesitant to initiate interactions due to their mistrust. Nurses should take the initiative to approach clients with suspicion in a respectful and neutral manner to gradually build rapport and trust.

A. A room without a window. B. A room containing personal belongings. C. A room adjacent to the nursing station. D. A room with dim lighting.

Correct Answer is B

Explanation

The correct answer is choice B. A room containing personal belongings.

Choice A rationale:

Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.

Choice B rationale:

A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.

Choice C rationale:

Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.

Choice D rationale:

Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

Correct Answer is B

Explanation

A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. The nurse recognizes that which of the following is an expected history associated with Wernicke-Korsakoff syndrome?

A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate that the client is experiencing maladaptive grief?

A nurse is taking care of an adult client who is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?

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A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift, the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?

A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification by the home health nurse?