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. 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.

A. Severe restlessness B. Respiratory depression and a comatose state C. Sore throat and muscle aches D. Increased anxiety and suicidal ideations

Correct Answer is C

Explanation

C. Agranulocytosis is a serious side effect associated with clozapine, an antipsychotic medication. Agranulocytosis is characterized by a severe reduction in the number of white blood cells (specifically granulocytes) in the bloodstream, leading to an increased risk of infection. The client should be educated to monitor for signs and symptoms of agranulocytosis, including sore throat, fever, chills, and muscle aches, as these may indicate an underlying infection due to neutropenia.

A. Severe restlessness may be a side effect of some antipsychotic medications, but it is not specifically associated with agranulocytosis.

B. Respiratory depression and a comatose state are not typical manifestations of agranulocytosis.

D. Increased anxiety and suicidal ideations may be symptoms of certain mental health conditions or adverse effects of psychiatric medications, but they are not characteristic of agranulocytosis.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been admitted for a psychiatric evaluation after displaying aggressive behavior towards their partner and 2-year-old child. Which of the following client statements should the nurse identify as potentially contributing to aggression?

Correct Answer is B

Explanation

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

Correct Answer is C

Explanation

A nurse is caring for a client who is concerned about developing a mental health disorder as a result of their childhood experiences. Which of the following familial characteristics is a protective factor for adverse childhood experiences?

A nurse is observing a group therapy session. Which of the following client statements should the nurse identify as an indication of bulimia nervosa?

A nurse is caring for a client who has asthma and allergies. The client asks the nurse about environmental influences they should avoid. The nurse should inform the client to avoid which of the following?

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?

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 is caring for a client who is requesting a prescription for a new medication. Which of the following actions should the nurse take?

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?