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 B
Explanation
B. An individual with anorexia nervosa often experiences fear or anxiety surrounding certain foods, particularly those perceived as high in calories or fat. This fear may lead to restrictive eating patterns and avoidance of certain food groups.
A. The primary motivation for restricting food intake is typically driven by factors such as fear of weight gain or body dissatisfaction, rather than simply disliking the taste of food.
C. They often meticulously monitor food intake and may keep detailed records of calorie consumption. Therefore, the statement about not tracking calories is less consistent with typical behaviors seen in anorexia nervosa.
D. People with anorexia nervosa often restrict their calorie intake well below recommended levels for maintaining health, and 2,000 calories per day would be considered a relatively high amount of food for someone with this disorder.
Correct Answer is C
Explanation
Delusions, hallucinations, and alterations in speech are characteristic symptoms of psychosis, which can occur in various psychiatric disorders such as schizophrenia. Dopamine antagonists, also known as antipsychotic medications, are the primary pharmacological treatment for psychosis.
A Mood stabilizers are primarily used to manage mood swings in conditions like bipolar disorder. While they can help stabilize mood, they are not typically the first-line treatment for psychotic symptoms like delusions and hallucinations.
B. SSRIs are antidepressant medications that primarily target serotonin levels in the brain. They are used to treat conditions such as depression, anxiety, and some other mood disorders.
D. Benzodiazepines are a class of medications primarily used to treat anxiety, insomnia, and seizures.
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