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.
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Related Questions
Correct Answer is D
Explanation
A. While this information can be helpful in understanding the patient's social context, it does not directly contribute to the development of a plan of care.
B. This information is important for understanding the patient's medical history and identifying any potential risk factors. However, a baseline assessment of physical and cognitive functioning is also essential for developing a comprehensive plan of care.
C. This assessment can be helpful in evaluating the patient's cognitive function, but it does not provide a complete picture of their overall physical and functional status.
D. When caring for an older adult in the emergency department, it is crucial to have a baseline understanding of their physical and cognitive functioning. This information will help the nurse assess the patient's current condition and identify any significant changes that may require intervention.
Correct Answer is B
Explanation
A. controlling the interview by selecting the memories to be discussed: Guided reminiscence should be a collaborative process between the nurse and the patient. The nurse should facilitate the conversation and encourage the patient to share their own memories, rather than imposing specific topics.
B. Guided reminiscence is a therapeutic technique that involves helping individuals recall and reflect on past experiences. The goal is to promote positive emotions, improve cognitive function, and enhance a sense of well-being.
C. While it may be helpful to break up the reminiscence sessions into shorter intervals, the focus should be on creating a comfortable and supportive environment for the patient to share their memories.
D. While it may be helpful to prompt the patient to recall specific memories, the emphasis should be on allowing the patient to freely explore their own memories and experiences.
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