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 A

Explanation

The correct answer is choice A: "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!”

Choice A rationale:

Correct Choice This statement reflects denial, which is a common response in the grief process. The client's refusal to accept the doctor's competence in treating their illness is an indication of their emotional struggle to come to terms with the diagnosis and prognosis.

Choice B rationale:

Feeling fatigued and lacking energy can be a physical manifestation of the grief process, but it does not specifically indicate denial. This statement could reflect depression or physical symptoms associated with the client's medical condition.

Choice C rationale:

Expressing gratitude and understanding for the doctor's efforts indicates acceptance, not denial. This statement suggests that the client has reached a point of acknowledging the doctor's attempts to provide care.

Choice D rationale:

ing the doctor's prognosis and assuming exaggeration indicates a negotiation stage of grief, where the client is trying to challenge the reality of their situation. However, this response does not specifically reflect denial as the primary phase of the grief process.

A. Use clarification to determine what the patient is feeling. B. Never break constant eye contact with the patient. C. Move the patient to a private area so the conversation will not be disturbed and cannot be seen. D. Speak to the patient using an authoritative voice and ask them, "Why are you acting this way?”

Correct Answer is A

Explanation

Choice A rationale:

When dealing with an angry and aggressive client, using clarification is an essential communication technique. It involves asking open-ended questions to better understand the patient's emotions and concerns, which can help defuse the situation and provide insight into the underlying issues.

Choice B rationale:

Maintaining constant eye contact can be interpreted as confrontational or aggressive behavior, potentially escalating the client's aggression. It's important to maintain a respectful distance and avoid behaviors that could exacerbate the situation.

Choice C rationale:

Moving the patient to a private area is a reasonable approach if the environment is contributing to the patient's agitation. However, the primary concern should be the safety of both the patient and the staff. Privacy can be important, but it shouldn't compromise safety.

Choice D rationale:

Speaking to the patient with an authoritative voice and asking "why" questions can escalate the situation further. It may come across as confrontational and provoke a defensive reaction from the patient. Open-ended questions that encourage the patient to express their feelings can be more effective in de-escalation.

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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

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