A nurse suspects that a client is experiencing alcohol withdrawal based on assessment of which of the following?

Bradycardia

Hypotension

Elevated temperature

Slurred speech

Answer and Explanation

The Correct Answer is C

A. Bradycardia: Alcohol withdrawal typically presents with tachycardia (increased heart rate), not bradycardia (decreased heart rate).

B. Hypotension: Alcohol withdrawal is more likely to cause elevated blood pressure rather than hypotension.

C. Elevated temperature: Elevated temperature is a common sign of alcohol withdrawal, which can be accompanied by other symptoms like tremors and agitation.

D. Slurred speech: Slurred speech is more associated with alcohol intoxication rather than withdrawal.

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Correct Answer is B

Explanation

A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.

B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.

C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.

D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.

A. Disorganized speech B. A hallucination C. An illusion D. Anhedonia

Correct Answer is B

Explanation

A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.

B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.

C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.

D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.

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A nurse suspects that a client is experiencing alcohol withdrawal based on assessment of which of the following?

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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A nurse suspects that a client is experiencing alcohol withdrawal based on assessment of which of the following?