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","D"]

Explanation

The correct answers are choices B and D: "Offer ideas for ways to distract or redirect the client." and "Educate the spouse about the availability of adult care as a respite."

Choice A rationale:

Suggesting a long-term care facility should not be the first action. Early-stage Alzheimer's clients can often remain at home with proper support, and suggesting institutionalization might not be appropriate at this stage.

Choice B rationale:

This is a correct choice. Engaging the client with Alzheimer's in activities that distract or redirect their focus can be helpful. This approach can alleviate the spouse's concerns and provide some relief from exhaustion.

Choice C rationale:

While discussing dementia care options with the spouse is important, it might not directly address the spouse's current exhaustion and feelings of helplessness.

Choice D rationale:

This is a correct choice. Educating the spouse about adult care options for respite can provide much-needed breaks for the caregiver. Caring for someone with Alzheimer's can be emotionally and physically draining, so respite care can offer temporary relief.

Choice E rationale:

Suggesting anti-anxiety drugs for the spouse is not the best first action. While addressing caregiver stress is important, suggesting medication should come after considering other supportive measures.

A. Aggressive behavior. B. Attention-seeking conduct. C. Mild fidgeting. D. Mild difficulty problem-solving.

Correct Answer is A

Explanation

Choice A rationale:

(Correct) Severe anxiety can lead to a fight-or-flight response, which might manifest as aggressive behavior. The individual might feel threatened and react defensively, potentially displaying aggressive actions to protect themselves.

Choice B rationale:

Attention-seeking conduct is less likely to be a primary manifestation of severe anxiety. While individuals with anxiety might seek reassurance or attention, the level of anxiety described here is more likely to evoke a defensive response rather than attention-seeking behavior.

Choice C rationale:

Mild fidgeting can be a manifestation of anxiety, but in the context of severe anxiety, the physical symptoms are often more pronounced, including restlessness, trembling, and muscle tension.

Choice D rationale:

Mild difficulty problem-solving is less likely to be a prominent manifestation of severe anxiety. Severe anxiety tends to affect the individual's ability to function and cope, leading to more intense and immediate reactions.

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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

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

Correct Answer is ["B","D"]

Explanation

A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

Correct Answer is A

Explanation

During a group therapy meeting, a client brings up a concern about the cleanliness of the bathroom. The nurse asks the group what should be done about the issue and how to resolve it. The nurse is demonstrating which type of leadership style?

A psychiatric nurse is caring for clients on a mental health unit during a group session. What should the nurse do to establish trust in a therapeutic relationship with the clients?

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A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?

A nurse is planning care for a client newly admitted with major depressive disorder. After ensuring safety, which of the following actions should the nurse plan to take?