A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

Decreased heart rate

Hyperthermia

Hyperglycemia

Decreased blood pressure

Answer and Explanation

The Correct Answer is B

Alcohol withdrawal syndrome is characterized by autonomic hyperactivity, which can manifest as tachycardia, hypertension, hyperthermia, diaphoresis, tremors, seizures, and delirium tremens. The nurse should monitor the client's vital signs, provide supportive care, and administer medications as prescribed to prevent complications and promote recovery.

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Correct Answer is D

Explanation

During the orientation phase, the nurse should introduce herself and the group members, explain the purpose and goals of the group, and create a trusting and respectful atmosphere. Maintaining focus, encouraging problem-solving, and managing conflict are actions that belong to the working phase of group development.

A. Obtain the provider's prescription within 60 min. B. Document the client's behavior every 15 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

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A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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