A nurse is assessing a client who is experiencing severe alcohol withdrawal. Which of the following findings should the nurse expect?
Heart rate 56/min
Dry skin
Temperature 38.6°C (101.5°F)
Drowsiness
The Correct Answer is C
A. Heart rate 56/min: Bradycardia is not typical during severe alcohol withdrawal. Instead, clients often exhibit tachycardia due to autonomic hyperactivity and increased sympathetic nervous system stimulation.
B. Dry skin: While skin changes can occur, dry skin is not a hallmark of alcohol withdrawal. Other findings such as diaphoresis, tremors, and pallor are more commonly observed.
C. Temperature 38.6°C (101.5°F): Fever is a common sign of severe alcohol withdrawal, reflecting the hypermetabolic state and autonomic hyperactivity associated with withdrawal. Elevated temperature, along with tachycardia, hypertension, and diaphoresis, indicates a more severe withdrawal process that requires close monitoring and intervention.
D. Drowsiness: Severe alcohol withdrawal typically presents with hyperalertness, agitation, and insomnia rather than drowsiness. Lethargy may suggest other complications, but it is not a typical manifestation of acute withdrawal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Eggs: Egg allergies are not relevant to thyroid scans, as the procedure does not involve egg-derived products. There is no increased risk of reaction during imaging for clients with egg allergy.
B. Latex: Latex allergy is a concern for equipment or supplies that contain latex, but it does not contraindicate a thyroid scan. Precautions can be taken with non-latex alternatives if needed.
C. Peanuts: Peanut allergy is unrelated to the substances used in thyroid scans, including radioactive iodine or contrast materials, and does not increase risk for this procedure.
D. Iodine: Iodine allergy is a contraindication because thyroid scans often involve radioactive iodine or iodine-containing contrast agents. Exposure can trigger severe allergic reactions, making it essential to identify and avoid iodine in clients with known allergy.
Correct Answer is A
Explanation
A. "Notify your provider if you experience muscle weakness.": Muscle weakness can be an early sign of hypokalemia, which increases the risk of digoxin toxicity by enhancing the drug’s effects on cardiac tissues. Prompt reporting helps prevent bradyarrhythmias and other serious complications associated with elevated digoxin sensitivity.
B. "Report a weight gain of one-half pound per day.": A gain of 0.5 lb per day is not typically used as a threshold for concern in heart failure management; providers generally focus on gains of 2–3 lb in a day or 5 lb in a week. This small fluctuation is often normal and may simply reflect fluid or dietary changes.
C. "Expect this medication to increase your blood pressure.": Digoxin does not raise blood pressure; its primary action is to improve myocardial contractility and slow heart rate through vagal stimulation. Clients should not expect hypertensive effects, and blood pressure changes are not a primary teaching point.
D. "You will need to take a diuretic while taking this medication.": A diuretic is not automatically required with digoxin because its use depends on the client’s underlying cardiac condition and fluid status. Some diuretics can worsen hypokalemia, increasing the risk for digoxin toxicity, so prescribing them requires careful provider evaluation.
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