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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Clenched teeth are a sign of unrelieved pain and indicate that the client needs more analgesia from the PCA pump. Difficulty swallowing, constipation, and urinary retention are common side effects of opioids and do not necessarily indicate unrelieved pain.
Correct Answer is D
Explanation
The correct answer is D.
Time of last pain medication. The nurse should include information that is relevant and essential for the continuity of care of the client, such as current assessment findings, interventions performed, response to treatment, and pending tests or procedures. The time of last pain medication is important to report because it affects the client's comfort level and mobility, and it helps the oncoming nurse plan when to administer the next dose of analgesia.
The steps required for dressing change are not necessary to report because they are usually standardized and documented in the policy manual or the care plan. The admission vital signs are not relevant to report because they do not reflect the client's current status. The preferred bath time is not essential to report because it can be obtained from the client or the chart.
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