The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Dilated pupils, tachycardia, elevated blood pressure, elation.

Excessive eating, constipation, headache.

Nausea, vomiting, diaphoresis, anxiety, tremors.

Mood lability, poor hand coordination, fever, drowsiness.

Answer and Explanation

The Correct Answer is C

A. Dilated pupils, tachycardia, elevated blood pressure, elation: These symptoms are more typical of stimulant intoxication and do not indicate alcohol withdrawal. They are not consistent with the need for a detox protocol focused on alcohol or other depressants.

B. Excessive eating, constipation, headache: These symptoms are not associated with alcohol or drug intoxication or withdrawal. They do not suggest a need for detoxification medication protocols.

C. Nausea, vomiting, diaphoresis, anxiety, tremors: These are classic signs of alcohol withdrawal and suggest the need for detoxification. These symptoms require immediate intervention to manage withdrawal safely and avoid complications.

D. Mood lability, poor hand coordination, fever, drowsiness: These signs are more indicative of intoxication with substances like sedatives. While concerning, they do not point to alcohol withdrawal, which requires specific detox protocols.

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Correct Answer is A

Explanation

A. Avoid straining at stool, bending, or lifting heavy objects: These activities can increase intraocular pressure and disrupt healing of the surgical site after cataract extraction. The client should be taught to avoid anything that could strain the eye and risk complications like hemorrhage or wound dehiscence.

B. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment:
Routine irrigation is not required and may introduce additional risk. Clients are instructed on proper hand hygiene and drop instillation rather than conjunctival irrigation.

C. Do not read without direct lighting for 6 weeks: While good lighting helps reduce eye strain, reading in lower light does not delay healing after cataract surgery. This instruction is unnecessary and could limit the client’s ability to resume normal activities.

D. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: Although bright light can be uncomfortable post-surgery, wearing sunglasses typically offers sufficient protection. There is no requirement to restrict sunlight exposure completely.

A. The woman is timid and speaks softly when asked about the accident. B. spiral fracture on the woman's arm and wrist. C. The woman is hyperventilating and appears to be in pain. D. Fresh bruises on the woman's shoulder and chest.

Correct Answer is B

Explanation

A. The woman is timid and speaks softly when asked about the accident: Timid behavior may suggest fear or anxiety, but it's nonspecific and may be due to trauma or emotional distress, not necessarily abuse.

B. Spiral fracture on the woman's arm and wrist: Spiral fractures occur from twisting injuries and are often associated with non-accidental trauma, especially when the injury doesn't match the reported mechanism.

C. The woman is hyperventilating and appears to be in pain: Hyperventilation and visible pain may indicate anxiety or physical injury, but they are expected after trauma and not unique to domestic violence.

D. Fresh bruises on the woman's shoulder and chest: Bruising is a possible sign of abuse, but bruises alone can result from a car accident. The type and location must be assessed in context.

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The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing an older adult client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

Correct Answer is A

Explanation

A woman and her live-in significant other come in the emergency department following a motor vehicle collision. Which finding should alert the nurse to assess for the possibility of domestic violence?

Correct Answer is B

Explanation

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