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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Related Questions
Correct Answer is D
Explanation
A. Tranylcypromine sulfate (Parnate) is a monoamine oxidase inhibitor (MAOI) that carries a high risk of toxicity in overdose and is generally avoided in patients with a history of suicide attempts.
B. Amitriptyline (Elavil) is a tricyclic antidepressant (TCA), which can be lethal in overdose, making it unsafe for patients at high risk for suicide.
C. Desipramine (Norpramin) is also a TCA and poses a similar overdose risk as amitriptyline, so it is not preferred for suicidal patients.
D. Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI), which has a much lower lethality in overdose compared to TCAs or MAOIs, making it the preferred choice for patients with a history of suicidal behavior.
Correct Answer is A
Explanation
A. "My family will be better off without me" is an indirect or covert suicidal statement (passive ideation) that suggests the patient believes others would be better off if they were gone. Such remarks require immediate assessment of suicide risk (ask directly about thoughts, intent, plan, access to means) and appropriate safety interventions.
B. "Life is not worth living" is an explicit expression of hopelessness and indicates suicidal ideation, but it is more overt than covert. It still warrants urgent assessment, but the question asked specifically for the covert message.
C. "I wish I were dead" is a direct statement of suicidal desire (overt) rather than a covert hint.
D. "I have a plan that will fix everything" is the most concerning because it indicates a specific plan (high lethality risk), but it is overt rather than covert.
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