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 C
Explanation
A. Singing carols is calm, unlikely to trigger combat-related flashbacks.
B. A seashore outing is generally peaceful and not typically a PTSD trigger.
C. Fireworks mimic gunfire and explosions, which can easily trigger flashbacks, hypervigilance, and distress in combat veterans with PTSD.
D. Halloween can be stimulating, but not as direct a combat reminder as fireworks.
Correct Answer is B
Explanation
A. Culturally influenced responses relate to behaviors shaped by cultural norms, not a temporary feeling of restlessness before a test.
B. Mild anxiety is characterized by increased alertness, restlessness, and improved concentration, which can actually enhance performance on tasks like taking a test.
C. Displacement is a defense mechanism in which emotions are transferred to a less threatening object or person, not simply feeling restless.
D. Trait anxiety refers to a long-term personality characteristic of being generally anxious, not a situational response before an exam.
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