Upon re-evaluation of the client, which of the following findings indicate that a change to the client's treatment plan is indicated?

The client says to the nurse in an authoritative voice, "Remove these restraints, I do not need them."

The client responds to the nurse's request and follows commands while being restrained.

The client asks the nurse to "Get my doctor on the phone, we need to talk about this situation."

The client tells another nurse that they are not a danger to themselves or others and to remove the restraints.

Answer and Explanation

The Correct Answer is B

Choice A reason: A verbal demand to remove restraints does not necessarily indicate improved behavioral control. The client may still pose a risk to themselves or others, and authoritative speech alone is not sufficient evidence of stabilization.

Choice B reason: Following commands and responding appropriately while restrained indicates improved behavioral regulation and decreased risk of harm. This suggests that the client may no longer require restraints, and the treatment plan should be reassessed to avoid unnecessary restriction of autonomy. Restraints are meant to be temporary and discontinued once the client demonstrates self-control.

Choice C reason: Requesting to speak with the doctor shows insight and willingness to engage in care but does not directly demonstrate behavioral stability. The client may still be agitated or unsafe, so this finding alone does not justify changing the treatment plan.

Choice D reason: Stating that they are not a danger does not guarantee safety. Clients with mania or agitation may lack insight into their condition, and verbal reassurance cannot replace objective behavioral assessment.

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Correct Answer is B

Explanation

Choice A reason: Varenicline is a partial nicotinic acetylcholine receptor agonist used for smoking cessation. It reduces cravings and withdrawal symptoms associated with nicotine dependence but has no role in managing acute alcohol withdrawal. Alcohol withdrawal involves hyperexcitability of the central nervous system due to the sudden absence of GABAergic stimulation, and Varenicline does not address this pathophysiology.

Choice B reason: Diazepam, a benzodiazepine, is the drug of choice for acute alcohol withdrawal. Benzodiazepines enhance GABA activity, counteracting the excitatory state caused by alcohol cessation. They reduce the risk of seizures, delirium tremens, and autonomic instability. Diazepam’s long half-life provides smoother withdrawal coverage and reduces rebound symptoms. Clinically, it is administered under close monitoring to titrate sedation and prevent complications.

Choice C reason: Disulfiram is an aversive agent used for long-term alcohol abstinence. It inhibits aldehyde dehydrogenase, causing accumulation of acetaldehyde when alcohol is consumed, leading to unpleasant symptoms such as flushing, nausea, and palpitations. However, it is contraindicated during acute withdrawal because it does not relieve withdrawal symptoms and may worsen the client’s condition if alcohol is ingested.

Choice D reason: Acamprosate is used for maintaining abstinence after detoxification. It modulates glutamatergic neurotransmission, reducing cravings and preventing relapse. However, it is not effective in treating acute withdrawal symptoms such as tremors, seizures, or delirium. Its role is supportive in long-term recovery, not immediate stabilization.

A. Lanugo B. Dental caries C. Cold extremities D. Amenorrhea

Correct Answer is B

Explanation

Choice A reason: Lanugo is a fine, downy hair that develops on the body as a compensatory mechanism in clients with anorexia nervosa due to severe malnutrition and low body fat. It is not typically associated with bulimia nervosa, since bulimia involves recurrent binge eating followed by compensatory behaviors such as vomiting or laxative use, but does not usually result in the same degree of starvation seen in anorexia.

Choice B reason: Dental caries are expected in bulimia nervosa because repeated self-induced vomiting exposes teeth to gastric acid. This acid erodes enamel, leading to tooth decay, sensitivity, and caries. This is a hallmark physical finding in bulimia and directly reflects the purging behavior characteristic of the disorder.

Choice C reason: Cold extremities are more commonly associated with anorexia nervosa due to severe malnutrition, hypothermia, and poor circulation from low body fat. Clients with bulimia nervosa may have normal weight or even be overweight, so cold extremities are not a typical finding.

Choice D reason: Amenorrhea is more characteristic of anorexia nervosa due to extreme caloric restriction and low body fat, which disrupts hormonal regulation of the menstrual cycle. While menstrual irregularities can occur in bulimia nervosa, amenorrhea is not a defining or expected finding.

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Upon re-evaluation of the client, which of the following findings indicate that a change to the client's treatment plan is indicated?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

Explanation

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