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.

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Correct Answer is D

Explanation

D. Furosemide is a diuretic that works by increasing urine output, which in turn reduces fluid retention and swelling. By tracking the client's weight on a daily basis, the nurse can obtain a clear and consistent measure of how much fluid is being lost as a result of the medication.
A. Monitoring respiratory status but it may not be the most direct method for evaluating the effectiveness of furosemide in reducing peripheral edema.
B. Monitoring serum protein levels may provide information about the client's nutritional status and liver function, but it is not typically used as a direct measure of response to furosemide for peripheral edema.
C. Improvement in peripheral pulses may indicate a reduction in fluid overload and resolution of edema. However, changes in peripheral pulses may be influenced by factors other than diuresis, such as vascular disease or cardiac function.

A. "Power and control are central to the dynamic of domestic violence." B. "Erratic relationships and vulnerability are central to the dynamic of domestic violence." C. "Poor communication and social isolation are central to the dynamic of domestic violence." D. "Emotional injury and learned helplessness are central to the dynamic of domestic violence."

Correct Answer is A

Explanation

A. Domestic violence is not simply about physical violence but also involves an imbalance of power where the abuser seeks to exert control over the victim through various means, including emotional, psychological, financial, and social manipulation.
B. Domestic violence can certainly lead to erratic relationships and exacerbate feelings of vulnerability but this statement does not capture the central dynamic of power and control that characterizes domestic violence.
C. Poor communication and social isolation can be contributing factors in some cases of domestic violence but they are not necessarily central to the dynamic.
D. This statement partially captures the psychological impact of domestic violence on victims, including emotional injury and learned helplessness. However, it does not explicitly address the underlying dynamic of power and control.

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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 administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

Correct Answer is D

Explanation

Which statement by an Emergency Department nurse indicates accurate knowledge of domestic violence?

Correct Answer is A

Explanation

The nurse is caring for a client who takes warfarin 10 mg PO daily and several herbal remedies. The nurse would be most concerned that the use of which herb would enhance the anticoagulant effects of warfarin?

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