A nurse is caring for a client in the emergency department (ED).
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Alcohol withdrawal syndrome refers to the collection of symptoms that occur when individuals who are dependent on alcohol abruptly reduce or stop their alcohol intake.
Benzodiazepines, such as diazepam or lorazepam, are commonly used to manage symptoms such as anxiety, tremors, and seizures.
Providing a safe environment also ensures that the client does not involve in self-harming activities due to hallucinations.
Alcohol withdrawal syndrome is associated with an increased risk of seizures, particularly within the first 48 hours after cessation of alcohol consumption. Seizures can range from mild to severe and may be life-threatening if not promptly managed.
Chronic alcohol abuse can lead to dehydration and electrolyte imbalances due to increased urinary output, decreased fluid intake, and poor nutrition. Additionally, alcohol withdrawal itself can exacerbate fluid and electrolyte disturbances due to vomiting, diarrhea, diaphoresis, and increased metabolic demand.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. This option promotes a calming and supportive environment that minimizes sensory stimuli and helps maintain orientation, reducing the risk of exacerbating symptoms of delirium and illusions.
A. Having the client sit by the nurse's desk may provide some supervision and reassurance, but keeping the television on can contribute to sensory overload and increase confusion, especially if the client is experiencing illusions.
C. Keeping the room shadowy with soft lighting and continuously playing a radio may create an environment that is disorienting and confusing for the client with delirium.
D. Maintaining bright lighting around the clock may disrupt the client's sleep-wake cycle and exacerbate symptoms of delirium. Interrupting the client's sleep by awakening hourly for mental status checks can also contribute to sleep deprivation and increase agitation and confusion
Correct Answer is C
Explanation
C. A neutral attitude communicates respect, professionalism, and non-threatening intentions. It helps to minimize the client's feelings of being scrutinized or manipulated and creates a safe environment for the client to engage in therapeutic interactions.
A. Disclosing personal information may further exacerbate the client's mistrust and suspicion, as they may interpret it as confirmation of their paranoid beliefs or as an attempt to manipulate them.
B. Approaching the client frequently throughout the day may be overwhelming and increase the client's suspicion. Clients with paranoid personality disorder often feel threatened by perceived intrusions into their personal space or privacy.
D. While it's essential to respect the client's autonomy and boundaries, waiting for the client to initiate interaction may prolong the establishment of a therapeutic relationship, especially with a client who is suspicious and mistrustful.
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