A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Support the client's coping skills.

Prevent the client from harming herself or others.

Identify the use of defense mechanisms.

Develop goals for treatment.

Answer and Explanation

The Correct Answer is B

A. Support the client’s coping skills. While important, safety takes precedence in the acute phase.

B. Prevent the client from harming herself or others. Alcohol withdrawal can lead to agitation, hallucinations, or seizures, making safety the nurse's priority.

C. Identify the use of defense mechanisms. This is part of long-term treatment, not immediate care.

D. Develop goals for treatment. Goal-setting is essential for long-term management but is not the priority during acute withdrawal.

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Correct Answer is B

Explanation

A. “Disulfiram will prevent my cravings for alcohol.” Disulfiram creates an aversion but does not reduce cravings.

B. "I should expect hand tremors to start less than 24 hours after I stop drinking." Tremors typically begin within 6-24 hours of the last drink.

C. "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage." Thiamine (Vitamin B1), not Vitamin C, is essential to prevent Wernicke’s encephalopathy and other complications.

D. "Withdrawal symptoms should last about 5 to 7 days once they begin." Withdrawal symptoms typically peak in 48-72 hours and subside after 4-5 days, not 7 days.

A. Decreased blood pressure B. Muscle aches C. Respiratory depression D. Hallucinations

Correct Answer is D

Explanation

A. Decreased blood pressure: Hypertension, not hypotension, is more common in alcohol withdrawal.

B. Muscle aches: Muscle aches are not typical for alcohol withdrawal.

C. Respiratory depression: Respiratory depression is not a feature of alcohol withdrawal but is more associated with opioid overdose.

D. Hallucinations: Visual, auditory, or tactile hallucinations may occur during severe withdrawal or delirium tremens.

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A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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