A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

Alcohol tolerance

Korsakoff's psychosis

Delirium tremens

Wernicke's encephalopathy

Answer and Explanation

The Correct Answer is C

A. Alcohol tolerance: Alcohol tolerance refers to the decreased effect of alcohol with repeated use, not withdrawal symptoms.

B. Korsakoff's psychosis: Korsakoff's psychosis is a chronic condition related to thiamine deficiency and characterized by memory impairment and confabulation, not acute withdrawal symptoms.

C. Delirium tremens: Delirium tremens (DTs) is a severe form of alcohol withdrawal that can present with tremors, agitation, elevated blood pressure, tachycardia, and confusion. The client’s symptoms and recent history suggest DTs.

D. Wernicke's encephalopathy: Wernicke's encephalopathy typically presents with ataxia, confusion, and ophthalmoplegia rather than the acute withdrawal symptoms described.

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Correct Answer is D

Explanation

A. Elevate the head of the bed: Elevating the head of the bed is not the priority during a seizure. The primary concern is ensuring the client's safety by preventing injury.

B. Restrain the client's arms and legs: Restraining a client during a seizure is not advised, as it can cause injury. Instead, the focus should be on protecting the client from harm.

C. Place a tongue blade in the client's mouth: Placing anything in the client’s mouth during a seizure is contraindicated, as it can lead to airway obstruction or injury.

D. Take measures to prevent injury: The priority during a seizure is to protect the client from injury by ensuring a safe environment, such as padding the head and moving any dangerous objects away.

A. drink adequate noncaffeinated and nonalcoholic beverages. B. take nutrient-dense foods or to combine plant-based proteins. C. take protein-based liquid supplements. D. get dental care and practice dental hygiene daily.

Correct Answer is A

Explanation

A. Drink adequate noncaffeinated and non-alcoholic beverages: Xerostomia (dry mouth) can be alleviated by staying hydrated with noncaffeinated and non-alcoholic beverages, which help to moisten the mouth and improve comfort.

B. Take nutrient-dense foods or to combine plant-based proteins: While nutrient-dense foods are important for overall health, they do not specifically address the issue of xerostomia. Plant-based proteins do not directly impact the symptoms of dry mouth.

C. Take protein-based liquid supplements: Protein-based liquid supplements are not specifically designed to address dry mouth and may not help in alleviating xerostomia.

D. Get dental care and practice dental hygiene daily: While dental care and hygiene are important for overall oral health, they do not specifically address xerostomia. Drinking fluids is more directly helpful for managing dry mouth.

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A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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