The client who is experiencing alcohol withdrawal has a temperature of 100.6 °F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?

Administer benzodiazepine as ordered.

Provide emotional support.

Encourage the client to rest.

Monitor for any further changes.

Answer and Explanation

The Correct Answer is A

A. Administer benzodiazepine as ordered: Benzodiazepines are the first-line treatment for alcohol withdrawal because they reduce central nervous system hyperexcitability, preventing seizures and delirium tremens. The client's elevated vital signs indicate severe withdrawal, requiring immediate pharmacologic intervention.
B. Provide emotional support: Emotional support is important, but in acute alcohol withdrawal with signs of autonomic hyperactivity, stabilizing the patient medically takes precedence over psychosocial interventions.
C. Encourage the client to rest: While rest may help reduce stimulation, it is not sufficient to control severe withdrawal symptoms. The client needs medication to prevent progression to life-threatening complications.
D. Monitor for any further changes: Ongoing monitoring is necessary, but immediate action is required first. Waiting without intervention in the face of escalating symptoms can lead to worsening instability, including seizures or hypertensive crisis.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Natural killer cells: Natural killer (NK) cells are a type of lymphocyte that patrol the body, identifying and destroying virus-infected and cancerous cells. They act rapidly without prior sensitization and play a key role in the innate immune response.
B. Cytokines: Cytokines are signaling proteins that help regulate immunity, inflammation, and hematopoiesis. They do not directly destroy infected or cancerous cells but mediate communication between immune cells.
C. Interleukins: Interleukins are a subset of cytokines that facilitate interactions between white blood cells. They support immune cell activation and proliferation but do not perform surveillance or direct cytotoxic actions.
D. Interferons: Interferons are proteins released by cells in response to viral infection. They enhance the immune response and inhibit viral replication but do not directly destroy infected or malignant cells like NK cells do.

A. "Life is challenging. I take it as it comes." B. "I am making it through and just barely holding on." C. "I am not able to juggle all of the balls of life." D. "What can you do, it is what it is."

Correct Answer is A

Explanation

A. "Life is challenging. I take it as it comes.": This statement reflects psychological hardiness — a resilience trait marked by commitment, control, and seeing stress as a challenge rather than a threat. It shows adaptive coping and a proactive mindset in facing life’s difficulties.
B. "I am making it through and just barely holding on.": This response indicates high stress and limited coping capacity. It suggests the person is overwhelmed, which is inconsistent with hardiness, which involves confidence in managing stress.
C. "I am not able to juggle all of the balls of life.": This reflects perceived helplessness and difficulty managing life's demands. It lacks the sense of control and adaptability associated with a hardy personality.
D. "What can you do, it is what it is.": While this may seem like acceptance, it reflects resignation more than resilience. A hardy individual typically views stressors as manageable and worth engaging with, not passively accepted.

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The client who is experiencing alcohol withdrawal has a temperature of 100.6 °F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer cells?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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