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 B

Explanation

Choice A rationale:

Circumstantiality refers to a communication pattern where the individual provides excessive, unnecessary details before reaching the point. In this scenario, the patient's response is not characterized by providing excessive details but rather by the use of words that sound alike but have no meaningful connection.

Choice B rationale:

Clang association is a communication pattern where the individual's speech is characterized by rhyming or the repetition of words that sound similar but lack logical connection. The patient's response, "This is a new day in May and I can't wait to play," demonstrates this pattern, as the words "May" and "play" rhyme but don't form a coherent sentence.

Choice C rationale:

Tangentiality refers to a communication pattern where the individual goes off-topic and never returns to the original subject. The patient's response, while seemingly off-topic, is not a clear example of tangentiality, as the words used are related in a rhyming manner rather than being entirely unrelated.

Choice D rationale:

Neologism refers to the creation of new words or phrases that are not part of any recognized language. The patient's response does not involve the creation of entirely new words; instead, it involves the use of existing words that rhyme but lack a coherent connection.

A. Instruct the client to sit down and stop pacing. B. Have a staff member escort the client to her room. C. Walk with the client at a gradually slower pace. D. Allow the client to pace alone until physically tired.

Correct Answer is C

Explanation

The correct answer is choice C. Walk with the client at a gradually slower pace.

Choice A rationale:

Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.

Choice B rationale:

Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.

Choice C rationale:

Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.

Choice D rationale:

Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.

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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).

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Naxlex Comprehensive Predictor Exams

The nurse is asking a diagnosed schizophrenic patient how they slept and they respond, "This is a new day in May and I can't wait to play." Which communication pattern does the nurse identify?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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