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. Hallucinations, particularly visual hallucinations, are a common manifestation of alcohol withdrawal, typically occurring within 12 to 24 hours after the last drink. These hallucinations can be vivid and may involve seeing objects, people, or animals that are not actually present.
A. Hypertension (high blood pressure) is more commonly associated with alcohol withdrawal, especially during the acute phase.
B. Respiratory depression, characterized by slowed or shallow breathing, is not a typical feature of alcohol withdrawal.
C. Muscle aches are not typically associated with alcohol withdrawal. Instead, symptoms such as tremors, agitation, and insomnia are more common during alcohol withdrawal.
Correct Answer is D
Explanation
D. Schizophrenia is typically diagnosed in young adulthood, usually in the late teens to early twenties, although it can also occur later in life. Symptoms often emerge during this period of development, characterized by disturbances in thinking, perception, emotions, and behavior.
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