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 C

Explanation

C. It indicates a positive childhood experience where the adolescent has a supportive and attentive teacher who listens well. Positive relationships with supportive adults, such as teachers, coaches, or mentors, can serve as protective factors for adolescents with anxiety disorders

A. This statement suggests that the adolescent experiences stress and worry related to their sibling's health problems, which may exacerbate their anxiety rather than serving as a protective factor.

B. This statement provides information about the adolescent's family background but does not necessarily indicate a positive childhood experience or protective factor for anxiety.

D. Frequent moves associated with military life may present challenges rather than protective factors for anxiety, such as disruptions in social relationships and support networks.

A. Stage 1 (mild) B. Stage 3 (severe) C. The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal. D. Stage 2 (moderate)

Correct Answer is B

Explanation

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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Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who has an anxiety disorder. Which of the following statements by the adolescent indicates a protective factor in the form of a positive childhood experience?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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