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)

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

C. Dissociative amnesia is characterized by difficulty remembering important personal information, typically of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. The manifestation of guilt is common in individuals experiencing dissociative amnesia, as they may feel guilty about their inability to recall events or about any actions that occurred during the period of amnesia.

A. Hallucinations involve perceiving sensations that are not present in reality, such as hearing voices or seeing things that others do not. While hallucinations can occur in various psychiatric disorders, they are not a typical manifestation of dissociative amnesia.

B. Delusions are false beliefs that are firmly held despite evidence to the contrary. Like hallucinations, delusions can occur in various psychiatric disorders, but they are not characteristic of dissociative amnesia.

D. Anhedonia refers to a reduced ability to experience pleasure or interest in previously enjoyable activities. It is not directly related to dissociative amnesia.

A. Identify emotion of faces on cards B. Repeat a list of words C. Interpret a sequence of pictures D. Imitate gestures of learned movements

Correct Answer is A

Explanation

A. Social cognition refers to the ability to understand and interpret social cues, including emotions, intentions, and interpersonal interactions. Asking the client to identify emotions on faces depicted on cards assesses their ability to recognize and interpret facial expressions, which is a fundamental aspect of social cognition.

B. Repeating a list of words primarily assesses verbal memory and recall, which may be impaired in dementia but does not specifically target social cognition.

C. Interpreting a sequence of pictures may assess aspects of visual processing, memory, and problem-solving abilities but does not specifically target social cognition.

D. Imitating gestures of learned movements may assess motor skills and imitation abilities but does not specifically target social cognition.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a client is who is recovering from an episode of dissociative amnesia. The nurse should expect the client to exhibit which of the following manifestations?

Correct Answer is C

Explanation

A nurse is caring for a client who has dementia. Which of the following requests should the nurse make to determine the client's social cognition?

Correct Answer is A

Explanation

A nurse is working with an older adult client who has been diagnosed with somatic symptom disorder. Which of the following should the nurse consider when working with an older adult who has somatic symptom disorder?

A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate for the client?

A nurse is providing care for a client who has schizophrenia. The client is unemployed and unhoused. Which of the following concepts regarding themselves should the nurse be aware of?

A nurse is caring for a client who asks the nurse, "May I please have your home address so that I can send you a note after I get home?" Which of the following responses should the nurse give?

A nurse is providing discharge teaching to a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

A nurse in an outpatient facility is teaching a client about the development of mental illness. Which of the following statements by the nurse describes the role of a vulnerability gene?

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns. Which of the following is the priority nursing intervention for this client?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, "I am not sure why I need to have a relapse plan." Which of the following responses should the nurse make?