A nurse in the emergency department (ED) is admitting a 46-year-old client.
Complete the following sentence by using the lists of options.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
- Encephalopathy is a common complication of severe alcohol withdrawal, characterized by altered mental status, confusion, and other neurological symptoms.
- Ammonia levels are often elevated in patients with alcohol withdrawal syndrome, and high ammonia levels can contribute to encephalopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Difficulty swallowing in a client with facial burns can indicate airway compromise due to edema and should be reported immediately as it may require urgent intervention to secure the airway.
B. While pain is a significant concern and should be managed, it is not as immediately life-threatening as potential airway obstruction.
C. A respiratory rate of 24 breaths per minute is elevated but within the range of mild tachypnea, which could be due to pain or anxiety, and is not the most urgent finding.
D. Urinary output of 25 mL/hr is below normal and indicates possible hypovolemia or kidney injury, but airway concerns take precedence in this scenario.
Correct Answer is A
Explanation
A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.
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