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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Voluntary admission does not remove a patient’s right to refuse treatment; informed consent is still required for all medications and procedures.

B. Clients admitted voluntarily retain the right to make decisions about their care, including providing informed consent for treatments and medications. This statement accurately reflects the client’s rights.

C. Healthcare providers are not allowed to disclose patient admission information without consent; confidentiality is maintained.

D. Voluntary patients have the right to request discharge, usually with a short notice period, even before a formal discharge summary is completed.

A. complains of prickly skin sensations B. demonstrates slowed verbal responses. C. paces aimlessly around the room. D. asks the nurse to repeat instructions.

Correct Answer is C

Explanation

A. Prickly skin sensations may occur with anxiety or substance use, not psychomotor agitation.

B. Slowed verbal responses indicate psychomotor retardation, not agitation.

C. Psychomotor agitation refers to increased, purposeless movement such as pacing, hand-wringing, or fidgeting.

D. Asking to repeat instructions indicates poor concentration, not specifically psychomotor agitation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include?

Correct Answer is B

Explanation

A patient is experiencing psychomotor agitation associated with bipolar disorder. Which observation would the nurse associate with this symptom? The patient

Correct Answer is C

Explanation

A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is associated with the child disorder? The child

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state. "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?

The nurse expects which medication to be prescribed to maintain abstinence to a patient with an addiction to either alcohol or opioids?

A nurse assesses a confused older adult. The nurse experiences sadness and reflects. This patient is like one of my grandparents... so helpless." Which response is the nurse demonstrating?

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A nurse is caring for a client who has bipolar disorder. Exhibits Which of the following assessment findings require immediate follow- up? (Select all that apply.)

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A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?