A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?
Tachycardia
Cramping
Seizures
Elevated temperature
The Correct Answer is C
Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The correct answer is A. The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are
incorrect because they can cause injury or discomfort to the client.
Correct Answer is D
Explanation
The correct answer is D. Limiting the number of choices for the client who has Alzheimer's disease can help reduce confusion and frustration and promote independence and dignity. Using written signs to assist the client with locating the bathroom may not be helpful, as the client may have difficulty reading or remembering what they mean. Using confrontation to manage the client's behavior can increase agitation and aggression and worsen cognitive decline. Providing a stimulating environment for the client can also overwhelm and overstimulate them and cause sensory overload.
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