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 A

Explanation

A. Sudden change in the client's behavior increases the risk of suicidal behavior and hence requires observation and exploration.
B. Reward the client for her change in behavior: Positive reinforcement can be helpful, but it’s
essential to focus on evidence-based interventions rather than rewards.
C. Open communication is valuable, but it’s essential to approach this conversation with sensitivity. The client may not fully understand the reasons for their sudden change in behavior.

D. Sudden change in the client's behavior increases the risk of suicidal behavior and hence requires observation and exploration. It is therefore, not safe to discharge teh client at this point

A. Have the client sit by the nurse's desk while awake in a room with the television on B. Provide a well-lit room without glare or shadows and limit noise C. Keep the room shadowy with soft lighting around the clock, and keep a radio on continuously D. Light the room brightly around the clock and awaken hourly to check mental status

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

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.)

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