A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?
Stage 1 (mild)
Stage 3 (severe)
The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal.
Stage 2 (moderate)
The Correct Answer is B
Stage 3 alcohol withdrawal, also known as delirium tremens (DTs), is characterized by severe manifestations, including hallucinations (such as seeing spiders crawling on the walls), disorientation, agitation, and potentially life-threatening physiological disturbances. The client's
belief that they are at home and calling for their mother indicates significant confusion and disorientation, which are common features of delirium tremens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The client's symptoms, including paranoia, perceptual disturbances (such as seeing things that aren't there), erratic behavior, and disorientation, are consistent with the effects of hallucinogens. Hallucinogens are a class of drugs that alter perception, mood, and cognitive processes.
A. Anabolic steroids are synthetic variations of the male sex hormone testosterone. They are primarily used to promote muscle growth and enhance athletic performance.
B Opioids are a class of drugs that include prescription pain relievers, such as oxycodone and morphine, as well as illegal drugs like heroin.
C. Stimulants, such as cocaine and amphetamines, can cause symptoms such as paranoia, agitation, and hallucinations, particularly at high doses or with chronic use. However, the client's symptoms of darting eyes, paranoia, yelling, mumbling, and gesturing are more suggestive of hallucinogen use rather than stimulant use.
Correct Answer is B
Explanation
B. Childhood experiences of physical abuse, such as being hit with fists by a parent, can significantly contribute to the development of aggressive behaviors later in life. Research has shown that individuals who have experienced physical abuse during childhood are at increased risk of displaying aggression towards others, including their partners and children, as adults.
A. This statement is less directly related to the client's own experiences of aggression and may not necessarily contribute directly to their current behavior.
C. and D do not directly address experiences of violence or abuse and are less likely to contribute directly to the client's aggressive behavior towards their partner and child.
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