A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

"Are you experiencing a relapse?"

"What time was your last drink?"

"How long have you had a problem with alcohol?"

"Are you having any liver problems?"

Answer and Explanation

The Correct Answer is B

A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.

B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.

C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.

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Correct Answer is B

Explanation

A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.

B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.

C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.

D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.

A. Thiamine deficiency B. Hypothalamic and mammillary body lesions C. Inability to learn new skills and short-term memory loss D. Double vision and rapid eye movement

Correct Answer is B

Explanation

A. Wernicke encephalopathy is caused by thiamine (Vitamin B1) deficiency, but it is not characterized by thiamine deficiency itself.
B. Wernicke encephalopathy is characterized by lesions in the hypothalamus and mammillary bodies in the brain.
C. While cognitive impairment may be present, this is not the primary characteristic of Wernicke encephalopathy.
D. Double vision and rapid eye movement are symptoms of Wernicke encephalopathy, but they are not the irreversible complication itself.

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A client is showing symptoms of alcohol intoxication. What question should the nurse ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

Correct Answer is B

Explanation

A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

Correct Answer is B

Explanation

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

The nurse is teaching about obstacles to maintaining recovery. Which of the following statements would indicate to the nurse a greater risk for relapse? (Select all that apply.)

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The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?

A newly admitted client diagnosed with paranoid schizophrenia is super vigilant and constantly scans the environment. The client states, "I saw doctors talking in the hall. They were plotting to kill me." Which of the following does the nurse correctly identify as this behavior?

What client population is at risk of developing tardive dyskinesia?