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 C

Explanation

The correct answer is choice C: "I'm hearing that you are concerned that it might turn out that you have cancer."

Choice A rationale:

Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.

Choice B rationale:

While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.

Choice C rationale:

This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.

Choice D rationale:

Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.

A. "Tell me what is concerning you.” B. "Crying helps us let things out and we feel better.” C. "Your husband is making really good progress.” D. "Did your husband say something to upset you?”

Correct Answer is A

Explanation

Choice A rationale:

The correct choice. In this situation, the nurse's priority is to gather information and provide emotional support. By asking the spouse to share their concerns, the nurse opens up a channel of communication and shows empathy, creating an opportunity to address the spouse's worries and provide reassurance.

Choice B rationale:

While the sentiment that crying can be cathartic and relieving is true, this response does not directly address the spouse's concern or encourage them to share their feelings. It's important to focus on the spouse's feelings rather than just explaining the benefits of crying.

Choice C rationale:

Assuming that the husband is making progress without knowing the specifics of the situation can come across as dismissive of the spouse's concerns. It's important to validate the spouse's emotions and provide support, rather than making assumptions about the husband's progress.

Choice D rationale:

Asking whether the husband said something to upset the spouse might be relevant, but it does not address the spouse's expressed concern about their husband. This response may not foster open communication and emotional support as effectively as choice A.

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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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Explanation

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Explanation

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