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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Most restrictive: A most restrictive environment may not be necessary if the client does not require intensive supervision or care.
B. Least restrictive: A least restrictive environment is generally preferred if the client can function with less supervision and support. It supports independence while providing necessary care.
C. Nursing home: A nursing home may be appropriate for clients needing extensive care, but it is often more restrictive than needed for clients who do not require 24-hour nursing care.
D. Transitional care unit: A transitional care unit is designed to support clients transitioning from hospital to home or other settings, which may be suitable if the client needs further rehabilitation or adjustment.
Correct Answer is A
Explanation
A. Tolerance: Tolerance occurs when an individual requires increasing amounts of a substance to achieve the same effect. This can explain why a person with a high blood alcohol level might not appear intoxicated if they have developed tolerance.
B. Addiction: Addiction is a chronic disease involving compulsive substance use. While related to tolerance, addiction itself does not specifically explain the lack of observable intoxication symptoms.
C. Alcoholism: Alcoholism is a condition involving dependency on alcohol. It can involve tolerance, but the term "alcoholism" does not specifically address the immediate observation of high alcohol levels without visible intoxication.
D. Relapse: Relapse refers to returning to substance use after a period of abstinence. It does not specifically explain the lack of visible intoxication despite high blood alcohol levels.
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