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. A child who uses the call light frequently B. A child whose parents answer questions for the child C. A child who has a BMI indicating obesity D. A child who has frequent visitors

Correct Answer is B

Explanation

B. This behavior may be concerning if it indicates a lack of autonomy or control over one's own communication. It could suggest overprotective or controlling behavior by the parents, which may be indicative of emotional abuse or neglect.

A. Frequent use of the call light may indicate a need for assistance or discomfort but does not necessarily indicate abuse. It could be related to the child's medical condition, anxiety, or other factors.

C. Childhood obesity itself is not necessarily indicative of abuse. It can result from a variety of factors, including genetics, dietary habits, and lifestyle factors.

D. Frequent visitors alone do not necessarily indicate abuse. However, it's important to consider the nature of the visitors' relationship with the child and whether they may pose a risk of harm.

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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 providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Correct Answer is B

Explanation

A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?

A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

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 client is seeking treatment for a specific phobia. The nurse in the anxiety disorders clinic documents that the client's anxiety is related to exposure to the phobic object. Which is a realistic outcome for anxiety self-control in this situation?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

The nurse is doing an admission assessment on a client with schizophrenia. Which of the following are positive symptoms of schizophrenia?

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply)