A nurse is caring for a client in the emergency department (ED).

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

D. Barbiturates can cause respiratory depression, hypoventilation, and potentially respiratory arrest, which can lead to hypoxia and cardiac arrest if not promptly recognized and managed.

A. While it's important to assess for any additional drugs or substances that the client may have ingested, this action is not the priority when managing a client with a barbiturate overdose.

B. Seizures can occur as a result of barbiturate overdose, but respiratory depression is the more immediate and life-threatening concern.

C. Ipecac is no longer recommended for the induction of vomiting in cases of drug overdose due to the risk of complications such as aspiration pneumonia and delayed treatment.

A. Provide a structured environment for the client. B. Identify the client's nutritional status. C. Plan a therapeutic diet for the client. D. Request a mental health consult.

Correct Answer is B

Explanation

A. A structured environment can include regular meal times, consistent routines, and clear expectations. While providing a structured environment is important in the overall management of eating disorders, it may not address the immediate concerns related to the client's severe weight loss and distorted body image.
B. Given the client's significant weight loss and distorted body image, assessing their nutritional status is crucial in understanding the extent of the problem and determining appropriateinterventions.
interventions. However, the client’s symptoms point to a mental health problem.
C. While planning a therapeutic diet is an essential component of the client's long-term treatment plan, it may not be the first priority given the client's current medical and psychological status.

D.Given the client's distorted body image, severe weight loss, and belief that she is fat, requesting a mental health consult is not the first priority. The physiological needs should be addressed first

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Naxlex Comprehensive Predictor Exams

A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

Correct Answer is D

Explanation

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is B

Explanation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

A nurse is caring for a client with paranoid personality disorder who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

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