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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
The correct answers are: a. Delayed language development, c. Spinning a toy repetitively, and e. Ritualistic behavior.
Explanation:
Choice A Rationale: Delayed language development is a common characteristic of autism spectrum disorder (ASD). Children with ASD may exhibit difficulties in acquiring and using language appropriately, including delayed onset of speech, limited vocabulary, and challenges with syntax and pragmatics. This delay can significantly impact their ability to communicate effectively and engage in social interactions. Early intervention strategies, such as speech therapy and alternative communication methods, are often implemented to support language development in children with ASD.
Choice B Rationale: Consistent limit testing, characterized by challenging authority and testing boundaries, is not a hallmark feature of autism spectrum disorder (ASD). While some children with ASD may exhibit behaviors that appear oppositional or defiant, such behaviors are more commonly associated with other conditions such as oppositional defiant disorder (ODD) or conduct disorder (CD). ASD is primarily characterized by deficits in social communication and interaction, along with restricted, repetitive patterns of behavior, interests, or activities.
Choice C Rationale: Spinning a toy repetitively is a stereotypical behavior often observed in children with autism spectrum disorder (ASD). Repetitive behaviors, including spinning objects, rocking back and forth, or hand-flapping, are considered one of the core diagnostic criteria for ASD. These behaviors serve various functions for individuals with ASD, including sensory stimulation, self-soothing, or reducing anxiety. While repetitive behaviors can vary widely among individuals with ASD, they are a recognizable feature of the disorder.
Choice D Rationale: A short attention span is not a specific characteristic of autism spectrum disorder (ASD). While some children with ASD may exhibit difficulties with attention and focus, particularly in tasks that do not align with their specific interests or preferences, attention deficits are not universal among individuals with ASD. Additionally, attention difficulties are not considered a primary diagnostic criterion for ASD. Other neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder (ADHD), are more commonly associated with impairments in attention and concentration.
Choice E Rationale: Ritualistic behavior, such as engaging in specific routines or repetitive actions, is a hallmark feature of autism spectrum disorder (ASD). Children with ASD often demonstrate a preference for predictability and sameness in their environment, leading to the development of rigid routines or rituals. These behaviors can serve as a source of comfort or security for individuals with ASD, providing structure and predictability in an otherwise unpredictable world. Ritualistic behaviors can manifest in various forms, such as insisting on following the same daily schedule, arranging objects in a specific order, or becoming distressed when routines are disrupted.
Correct Answer is A
Explanation
The correct answer is choice A: Request a mental health consult.
Choice A rationale:
Requesting a mental health consult is the first priority in this situation. The client's significant weight loss, distorted body image, and belief that she is fat suggest potential body dysmorphic disorder, eating disorder, or other psychological concerns. It's crucial to address these underlying issues before focusing on other aspects of care.
Choice B rationale:
Providing a structured environment can be beneficial, but it might not address the root cause of the client's psychological distress and distorted body image.
Choice C rationale:
Assessing the client's nutritional status is important to understand the physical impact of the weight loss, but the urgent need here is to address the client's psychological well-being and distorted self-perception.
Choice D rationale:
Planning a therapeutic diet for the client is essential, but it should not be the first priority. The client's belief that she is fat and her significant weight loss indicate deeper psychological issues that require immediate attention. Without addressing these psychological concerns, focusing solely on a diet plan might exacerbate her distorted body image and eating behaviors.
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