A hospitalized client diagnosed with alcohol use disorder believes spiders are spinning webs in the room to entrap him. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?
Keep the room dimly lit
One-on-one supervision
Force fluids
Check the patient every 15 minutes
The Correct Answer is B
A. A dimly lit room can increase misperceptions and hallucinations, worsening fear.
B. The client is experiencing alcohol withdrawal delirium with hallucinations, agitation, and high risk for injury. Continuous monitoring ensures safety and allows immediate intervention.
C. Hydration is important, but it is not the priority compared to preventing injury during hallucinations.
D. Intermittent checks are not enough; the client requires continuous supervision for safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Confidentiality does not end when a client dies; healthcare professionals are still required to protect the privacy of medical records and disclosures.
B. This reflects the "duty to warn" principle (Tarasoff ruling), which legally obligates providers to take reasonable steps to protect identifiable individuals if a client poses a threat of harm. This is a recognized exception to confidentiality.
C. Healthcare workers must comply with court orders or subpoenas requesting medical information. Refusing is not legally permissible.
D. Attorneys do not automatically have access to client information; a legal order is required. Confidentiality is not broken based on an attorney’s request alone.
Correct Answer is C
Explanation
A. Anger is a common emotion in psychiatric patients but is less predictive of suicide risk.
B. Elation may occur in some mood disorders but is not strongly associated with imminent suicide risk.
C. Hopelessness is the feeling most strongly correlated with suicidal ideation and attempts, making it a key predictor for elevated suicide risk.
D. Sadness is a symptom of depression but alone does not reliably predict suicide risk without accompanying hopelessness.
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