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.

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Correct Answer is B

Explanation

B. Dissociative identity disorder (DID) can affect individuals of any age, including children. While treatment approaches may vary depending on the age of the individual and their specific needs, one aspect that remains consistent across age groups is the importance of assessing for thoughts of self-harm or suicidal ideation.

A. Nursing interventions for dissociative identity disorder (DID) can be diverse and tailored to the individual needs of the patient, regardless of age. While managing DID in children may present some unique challenges compared to adults, it doesn't mean that nursing interventions are limited. This option may not provide helpful information to the guardian seeking guidance.

C. Treatment outcomes for DID can vary widely depending on various factors, including the severity of symptoms, the presence of comorbid conditions, the quality of therapeutic interventions, and the individual's support system. While some older individuals may respond well to treatment, age alone is not a determining factor in treatment outcomes.

D. Dissociative identity disorder can occur in both children and adults, and psychiatric medication may be prescribed to individuals of any age depending on the severity of symptoms and individual treatment plans. Medication is often used to manage comorbid conditions such as depression, anxiety, or mood disorders that commonly co- occur with DID.

A. Secondary prevention B. Primary prevention C. Tertiary prevention D. Quaternary prevention

Correct Answer is B

Explanation

B Primary prevention aims to prevent the onset of a disease or health condition before it occurs. In the context of sexually transmitted infections (STIs), providing education and information about safe sex practices, condom use, and strategies for preventing STIs constitutes primary prevention efforts.

A. Secondary prevention involves early detection and intervention to prevent the progression of a disease or health condition. Examples include screening for STIs and providing prompt treatment to individuals who test positive.

C. Tertiary prevention focuses on managing and reducing the impact of existing disease or health conditions and preventing complications or disability. In the context of STIs, tertiary prevention efforts may include providing ongoing medical care, support, and education to individuals living with STIs

D. Quaternary prevention aims to mitigate or avoid the consequences of unnecessary or excessive healthcare interventions and to protect individuals from overmedicalization. It focuses on promoting prudent and ethical healthcare practices.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing treatment options with the guardian of a child who has been diagnosed with dissociative identity disorder. The guardian asks. "How is nursing care different for children diagnosed with dissociative Identity disorder compared to adults?" How should the nurse best respond?

Correct Answer is B

Explanation

A nurse is presenting information about the prevention of sexually transmitted infections to a group of high school students. The nurse should identify that this is an example of which of the following types of prevention?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing fluctuating cognition and visual hallucinations. Which of the following types of dementia should the nurse expect this client to have?

A nurse is caring for a 50-year-old client who is being evaluated for late-onset schizophrenia. Which of the following findings should the nurse expect?

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 teaching the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

A nurse is caring for a client who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this client?

A nurse is presenting an in-service about the cycle of violence to nursing staff. The nurse should include that which of the following occurs during phase 1 of the cycle of violence?

A community health nurse is conducting a presentation about modifiable risk factors at a local community center. A community member asks a question and the nurse does not know the answer. Which of the following actions should the nurse take?

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?