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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

This response uses a confrontational tone and places blame on the client for their behavior, which is not an example of assertive communication. It can potentially escalate the situation and hinder effective communication.

Choice B rationale:

This statement is authoritarian in nature, using phrases like "you need to" and "forgive me," which can further upset the client and create a power struggle. It lacks empathy and understanding, making it ineffective for assertive communication.

Choice C rationale:

While this response acknowledges the consequences of the client's negative behavior, it uses commanding language ("you better go to your room"), which can be perceived as aggressive and may escalate the situation instead of facilitating effective communication.

Choice D rationale:

This statement is the most effective example of assertive communication. It acknowledges the client's feelings ("I understand that you are angry") while also asserting the nurse's adherence to protocol. This response demonstrates empathy, understanding, and a willingness to address the client's emotions in a non-confrontational manner.

A. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!” B. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.” C. "The doctor has been so good to me. I know he has tried everything he can. It is just my time.” D. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.”

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: This statement reflects anger and frustration, which are characteristic of the anger stage of grief. The individual is expressing disbelief in the doctor's competence but is not denying the reality of their diagnosis.

Choice B rationale: This statement indicates acceptance and acknowledgment of the physical effects of the disease. The client recognizes their lack of energy but is not denying their condition, suggesting they are in a more advanced stage of the grieving process.

Choice C rationale: This statement reflects acceptance of the situation and gratitude towards the doctor. The client acknowledges the efforts made by the medical team and recognizes the inevitability of their condition, indicating they are in the acceptance stage of grief.

Choice D rationale: This statement indicates denial as the client doubts the doctor's prognosis and believes the doctor is exaggerating. Denial is a common initial reaction where the individual struggles to accept the reality of their diagnosis, instead choosing to believe it is not as severe.

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A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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