A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
Start intravenous fluids.
Administer diazepam.
Obtain a medical history.
Raise the side rails of the bed.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Providing an activity schedule that changes from day to day might be overwhelming and confusing for a client with Alzheimer's disease, as routine and predictability are often more beneficial.
B. Constantly rotating caregivers can lead to increased confusion for the client, as familiarity and consistency are important in their care.
C. Limiting time for the client to perform activities can add unnecessary stress and may not be conducive to a comfortable and supportive environment for someone with Alzheimer's disease.
D. Talk the client through tasks one step at a time.
For a client with Alzheimer's disease, providing clear and simple instructions is crucial. Breaking tasks down into manageable steps helps the client follow and complete activities more effectively. This approach reduces confusion and frustration and promotes the client's ability to engage in activities of daily living.
Correct Answer is ["B","D","E"]
Explanation
A. Nystagmus: Nystagmus is not a typical manifestation of alcohol withdrawal. It is more commonly associated with intoxication or neurological conditions. Therefore, it is not included in the effects of alcohol withdrawal.
B. Illusions: Illusions (misinterpretations of external stimuli) are common during alcohol withdrawal, especially in severe cases such as withdrawal delirium (delirium tremens). Clients may misinterpret shadows or objects as threatening.
C. Polyphagia: Polyphagia (excessive eating) is not a recognized manifestation of alcohol withdrawal. Clients with withdrawal may experience nausea or a lack of appetite rather than an increased appetite.
D. Tremors: Tremors, often called "the shakes," are one of the most common early signs of alcohol withdrawal. They usually begin within hours after alcohol cessation.
E. Seizures: Seizures, specifically generalized tonic-clonic seizures, are a serious complication of alcohol withdrawal. They can occur within 6–48 hours after the last drink and are part of alcohol withdrawal syndrome.
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