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
Explanation
A. Referring the patient to a minister avoids the nurse’s responsibility to provide immediate therapeutic support.
B. This response reflects the patient’s feelings and encourages further expression, which is therapeutic in depression.
C. Asking “why” can feel judgmental and place the patient on the defensive, which is non-therapeutic.
D. Giving false reassurance or imposing religious beliefs does not address the patient’s feelings and may shut down communication.
Correct Answer is D
Explanation
A. Referral of a formerly suicidal patient to a support group is a form of tertiary prevention, aimed at preventing recurrence and promoting recovery after an event.
B. Psychiatric hospitalization of a suicidal patient is considered secondary prevention, targeting individuals at immediate risk to prevent harm.
C. Suicide precautions for 24 hours for newly admitted patients is secondary prevention, focused on intervening during a high-risk period.
D. Helping school children learn to manage stress and be resilient is primary prevention, aimed at preventing the onset of suicidal behaviors before any signs or risk factors appear.
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