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

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.

A. "You will need to take this medication on an empty stomach.” B. "You will need to consume a low-salt diet while on this medication.” C. "You will need your blood levels drawn weekly during the first month.” D. "You will need to stop this medication if you develop severe diarrhea.”

Correct Answer is C

Explanation

Choice A rationale:

Ingesting lithium (Eskalith) on an empty stomach can lead to gastrointestinal upset. Therefore, clients are generally advised to take this medication with food or milk to minimize these side effects. This choice is incorrect.

Choice B rationale:

While sodium intake can impact lithium levels, clients are usually advised to maintain a consistent, moderate sodium intake rather than adopting a low-salt diet. Extreme dietary changes can affect lithium levels and potentially lead to toxicity, making this choice inaccurate.

Choice C rationale:

Monitoring blood levels of lithium is crucial to ensure therapeutic effectiveness and prevent toxicity. During the initiation phase, frequent monitoring, typically weekly, is necessary to establish the appropriate dosage for each individual. Lithium has a narrow therapeutic range, and blood levels need to be closely regulated.

Choice D rationale:

Discontinuing lithium abruptly can lead to worsened bipolar symptoms. Diarrhea can contribute to dehydration and electrolyte imbalances, potentially impacting lithium levels, but stopping the medication is not the initial action to take. Adjustments in dosage or management strategies are usually explored before considering discontinuation.

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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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