The nurse is assessing patients for impending alcohol withdrawal. The nurse assesses the patient with which of the following conditions as a priority?
Reporting muscle aches and frequent stumbling
Dozing off in chair and not recognizing staff
Pulse. 118 beats/min; and BP 160/90
Pulse, 58 beats/min; and BP 100/60
The Correct Answer is C
A. While these symptoms can be associated with alcohol withdrawal, they are not as indicative of an immediate medical emergency as tachycardia and hypertension.
B. While these symptoms may suggest cognitive impairment, they are not as indicative of impending alcohol withdrawal syndrome as tachycardia and hypertension.
C. Alcohol withdrawal can lead to various physiological changes, including increased heart rate and blood pressure. A pulse of 118 beats/min and a blood pressure of 160/90 indicate a significant increase in both vital signs, which could be a sign of impending alcohol withdrawal syndrome.
D. These vital signs are within normal limits and do not indicate a significant risk of alcohol withdrawal syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This question is specific to a potential complication of diabetes, but it does not directly assess the patient's understanding of their current health problems or the importance of self-monitoring blood glucose levels.
B. This question is about a specific laboratory result, but it does not assess the patient's understanding of the importance of self-monitoring blood glucose levels.
C. This question assesses the patient's understanding of the importance of self-monitoring blood glucose levels, which is crucial for managing diabetes. By understanding the reasons behind this intervention, the patient is more likely to comply with the treatment plan and make informed decisions about their health.
D. This question is about the logistics of medication management, but it does not assess the patient's understanding of their current health problems or the importance of self-monitoring blood glucose levels.
Correct Answer is ["A","B","D"]
Explanation
A. The patient's mental status is crucial for understanding their current cognitive and emotional condition. This information helps the incoming nurse assess whether there have been any changes or concerns regarding the patient's orientation, mood, or cognitive function.
B. Documenting all pertinent nursing care provides a comprehensive overview of what has been done for the patient during the shift, including any treatments, medications administered, and changes in the patient's condition.
C. While knowing who visited the patient might be relevant in some contexts, it is generally not a core component of clinical shift reports unless the visitors' presence impacted patient care or the patient’s condition. This information is usually not necessary for the shift report unless it directly affects the
patient’s care or treatment, such as if a visitor brought important information or had a significant impact on the patient.
D. The status of lung sounds is a specific aspect of the patient's physical assessment and can indicate respiratory issues or improvements. This data is necessary if the patient has a respiratory condition or if there have been recent changes in their respiratory status. It helps the incoming nurse evaluate the effectiveness of treatments and ongoing respiratory care.
E. Information about the patient's favorite TV shows is not relevant to clinical care and does not impact
the patient’s health status or the nursing interventions required. This information is not necessary for
the shift report as it does not contribute to the patient’s medical or care needs.
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