A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).
Tremors.
Insomnia.
Severe hypotension.
Hyperglycemia.
Visual hallucinations.
Correct Answer : A,B,E
Choice A rationale:
Tremors. Rationale: Tremors can be a withdrawal symptom associated with alcohol withdrawal. These tremors are often referred to as "alcohol shakes" and are a result of the central nervous system adapting to the sudden absence of alcohol.
Choice B rationale:
Insomnia. Rationale: Insomnia is a common withdrawal symptom during alcohol withdrawal. Alcohol disrupts sleep patterns, and when a person stops drinking, their sleep cycle may be disturbed, leading to difficulty falling asleep or staying asleep.
Choice C rationale:
Severe hypotension. Rationale: Severe hypotension, or very low blood pressure, is not a prominent withdrawal symptom of alcohol. Alcohol withdrawal can lead to an increase in blood pressure rather than severe hypotension.
Choice D rationale:
Hyperglycemia. Rationale: Hyperglycemia, or high blood sugar, is not a direct withdrawal symptom of alcohol. However, chronic alcohol use can affect blood sugar regulation over time. During acute withdrawal, hypoglycemia (low blood sugar) is more common due to altered metabolism.
Choice E rationale:
Visual hallucinations. Rationale: This statement is correct. Visual hallucinations can occur during alcohol withdrawal and are often indicative of a more severe withdrawal syndrome known as delirium tremens (DTs). DTs can include visual hallucinations, confusion, agitation, and autonomic hyperactivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: "I am powerless against my addiction to alcohol."
Choice B rationale:
This statement reflects an understanding of one of the fundamental principles of Alcoholics Anonymous (AA), which is the acknowledgment of powerlessness over alcohol. The concept of powerlessness is a cornerstone of the 12-step program and encourages individuals to recognize that attempting to control their addiction often leads to negative consequences. This admission is crucial for clients in recovery, as it opens the door to seeking support and relying on the fellowship and guidance of AA.
Choice A rationale:
While identifying triggers for alcoholism is important, this statement does not directly capture the essence of AA's principle. The focus on identifying causes does not fully encompass the concept of powerlessness over the addiction.
Choice C rationale:
Responsibility for one's alcoholism is not a core principle of AA. Instead, the program encourages individuals to take responsibility for their actions and their commitment to recovery, but not for causing their addiction in the first place.
Choice D rationale:
AA is a peer support program that emphasizes personal responsibility and self-accountability. While counseling might be beneficial, the statement implies external responsibility for recovery, which contradicts the self-help nature of AA.
Correct Answer is C
Explanation
Choice A rationale:
While wanting to go home to be with loved ones can be a sign of distress, it doesn't necessarily indicate an immediate risk of suicide. Many individuals express a desire to be with family when feeling down, and this statement alone is not a definitive indicator of suicide risk.
Choice B rationale:
Engaging in social activities like playing basketball with others is generally a positive sign, as it indicates some level of interaction and engagement. This choice is less likely to indicate an immediate suicide risk.
Choice C rationale:
The client demonstrating increased impulsive behaviors is a concerning sign. Rapid and impulsive actions can potentially lead to self-harm or dangerous situations. Increased impulsivity can indicate a lack of consideration for consequences, which may elevate the risk of suicidal behaviors.
Choice D rationale:
Identifying with problems expressed by other clients is not a specific indicator of suicide risk. While it may suggest empathy and shared experiences, it doesn't directly address the immediate risk factors related to the client's bipolar disorder.
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