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.
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.
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Related Questions
Correct Answer is D
Explanation
D. Histrionic personality disorder (HPD) is characterized by a pattern of excessive emotionality and attention-seeking behavior. Individuals with HPD often display dramatic, flamboyant, or exaggerated emotions and may use seductive or provocative behavior to capture the attention of others.
A. Histrionic personality disorder (HPD) is characterized by attention-seeking behavior, emotional instability, and a strong desire for excitement and novelty. They are less likely to be preoccupied with minute details or exhibit perfectionistic traits, which are more commonly associated with obsessive- compulsive personality disorder (OCPD).
B. Grandiosity, self-importance, and a sense of entitlement are characteristic features of narcissistic personality disorder (NPD), not histrionic personality disorder (HPD).
C. Difficulty being alone, indecisiveness, and submissiveness are more commonly associated with dependent personality disorder (DPD), not histrionic personality disorder (HPD).
Correct Answer is C
Explanation
C. This statement raises significant concern for possible emotional or psychological abuse. Comparing the child unfavorably to siblings and implying that the child is not as "good" as others could indicate a pattern of emotional maltreatment.
A. This statement does not raise suspicion of child abuse. It merely describes the child's intelligence and does not provide any indication of potential abuse.
B. it is possible for children to sustain injuries due to clumsiness or accidents but this statement alone does not necessarily raise suspicion of child abuse.
D. This statement, on its own, does not necessarily indicate child abuse.
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