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 B
Explanation
A. Limiting the number of visitors may be a necessary step if the patient is becoming overwhelmed or tired. However, this approach might not consider the cultural significance of extended family and community in Arab American culture, where family involvement is often highly valued.
B. Suggesting shorter visits is a more balanced approach. It acknowledges the patient's need for rest while still respecting the importance of family and community involvement. This action can help manage the patient's fatigue while allowing them to maintain cultural and familial connections. It’s a compromise that accommodates both the patient's health needs and cultural values.
C. Requiring visitors to check in at the front desk can help manage visitor flow and ensure that the patient is not overwhelmed. However, this action does not directly address the issue of visitor duration or frequency, which might still lead to patient fatigue. It also might not align with cultural expectations of openness and hospitality in Arab American culture, where family and visitors are often seen as central to the patient’s well-being.
D. Allowing only family members to visit might help reduce the number of visitors and ensure that the patient receives support from those closest to them. However, this approach may be too restrictive and could potentially isolate the patient from their broader support network, which might be an important aspect of their cultural practices. It also does not address the underlying issue of managing visitor fatigue.
Correct Answer is D
Explanation
A. The term "State Practice Act" is not a standard term used to describe the specific law governing nursing practice. It is a broader term that could refer to various state laws related to professional practice in general, not specifically nursing.
B. A "Legislative Act" is a general term for any law passed by a legislative body. It is not specific to nursing or to the regulations surrounding nursing practice. While the Nurse Practice Act is indeed a legislative act, this term does not specifically define the nursing regulations and licensure requirements.
C. The term "Nurse Regulation Act" is not commonly used or recognized as the official name of the law governing nursing practice. It might imply a focus on regulations but does not accurately reflect the official and widely accepted terminology.
D. The Nurse Practice Act is the correct term. This law defines the scope of practice for nurses, regulates the practice of nursing within a state, and establishes the requirements for obtaining and maintaining licensure. It outlines the legal parameters within which nurses must operate and is specific to the practice of nursing. The Nurse Practice Act ensures that nursing professionals meet certain standards of competency and ethical practice.
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