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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","F","I"]
Explanation
A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.
Correct Answer is A
Explanation
A. Justice refers to fairness and equality in the distribution of care and resources. The nurse is concerned about whether patients exhibiting similar behaviors (self-mutilation) are being treated consistently and fairly, which directly relates to the principle of justice.
B. Fidelity involves keeping promises and commitments to patients, which is not the primary concern in this scenario.
C. Beneficence involves acting in the patient’s best interest to promote well-being. While relevant to care decisions, the main ethical issue here is fairness between patients.
D. Autonomy involves respecting a patient’s right to make their own decisions, which is not the central issue in comparing the care of two patients.
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