The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

orient to reality.

identify social supports.

replace fluids.

apply restraints.

Answer and Explanation

The Correct Answer is C

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D. Conveying an accepting attitude involves demonstrating empathy, respect, and non-judgmental acceptance of the client as they are. Clients with BPD often have a fear of rejection and abandonment, so feeling accepted and understood by the nurse is critical for building trust.
A. In the early stages of group intervention, clients may not yet feel comfortable engaging in deep self-reflection without first establishing trust in the nurse and the group.
B. Identifying community resources is important for comprehensive care, but it may not be the most essential aspect initially for establishing trust.
C. Providing positive feedback can help reinforce positive behaviors and build rapport with clients, but it may not be the most essential aspect initially for establishing trust.

A. strong positive feelings lead to underinvolvement with the victim. B. awareness protects one's own mental health. C. strong negative feelings interfere with assessment and judgment. D. positive feelings promote the development of sympathy for clients.

Correct Answer is C

Explanation

C. This awareness is crucial because personal emotions can cloud professional judgment, leading to bias in assessing the situation and making decisions. It's important for healthcare professionals to maintain a level of emotional detachment in order to provide the most objective and effective care.
A. Positive feelings alone are not likely to lead to underinvolvement. Instead, the risk lies more in becoming overly empathetic or emotionally attached, which could cloud judgment or compromise professional objectivity.
B. Recognizing and acknowledging one's own feelings while working with families experiencing domestic violence can help prevent emotional burnout and maintain mental well-being. However, this does not relate directly to domestic violence.
D. Experiencing only positive feelings without acknowledging the complexities and challenges of the situation may hinder the nurse's ability to provide comprehensive care and support to the victim.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

Correct Answer is D

Explanation

The rationale for the nurse needing to be aware of their own feelings while working with the family experiencing domestic violence is best explained as:

Correct Answer is C

Explanation

The nurse is scheduled to interview a client with histrionic personality disorder. The nurse can anticipate that the assessment findings will include the following. The client:

When doing an admission assessment of a client with a history of alcoholism, the most important factor(s) to assess is/are:

The best action for the nurse to take with a 5-year-old who runs over to another child in the waiting room and slaps her is to:

A 7-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. The nurse should monitor for which desired outcome?

A fifteen-year-old was referred to the adolescent mental health clinic after being arrested for prostitution. The client's parents reported that they have run away several times and is abusive towards them. The nurse should anticipate that the diagnosis will be:

When assessing the client diagnosed with schizotypal personality disorder, the nurse expects to identify which characteristic behavior?

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?

A college student experienced a sexual assault when out on a date. After several weeks of crisis intervention therapy, which statement by the client would indicate to the nurse that the student is making progress?