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 A

Explanation

A. When a nurse observes illegal or unethical behavior, such as stealing narcotics, it is their ethical and legal responsibility to report the incident promptly to the appropriate authorities.

B. While it's important to encourage the coworker to seek treatment for their substance abuse issue, withholding reporting of the incident compromises patient safety and violates organizational policies and legal obligations. It's essential to report the incident regardless of the coworker's actions afterward.

C. Reporting the incident to other RNs on the shift may not be sufficient action to address the seriousness of the situation. While it's important for colleagues to be aware of potential risks to patient safety, the primary responsibility lies with reporting the incident to the appropriate authorities within the organization.

D. Agreeing not to report the incident in exchange for the coworker promising to report themselves to the supervisor is not an appropriate course of action. It's essential to follow established reporting protocols and ensure that the incident is documented and addressed through the appropriate channels to protect patient safety and uphold professional standards.

A. Manipulation B. Marginalization C. Codependency D. Enabling

Correct Answer is C

Explanation

C. Codependency refers to a dysfunctional pattern of behavior in which a person excessively relies on another individual (often a partner or family member) for their sense of identity, self- worth, or emotional well-being. In this scenario, the partner's demand to see the client's records

and treatment plan, as well as the assertion of needing to oversee the treatment, suggests an excessive need for control and involvement in the client's life and healthcare decisions.

A. Manipulation involves influencing or controlling someone in a deceptive or dishonest way to achieve one's own goals.

B. Marginalization refers to the exclusion or relegation of a person or group to a lower or outer edge of society or a group.

D. Enabling refers to behaviors that unintentionally or intentionally allow someone to continue engaging in harmful behaviors or avoid facing consequences.

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Naxlex Comprehensive Predictor Exams

A staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

A nurse is caring for a client who has a new diagnosis of somatic symptoms disorder. The nurse should identify that the client must have been experiencing manifestations of the disorder for how long before diagnosis?

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?

A nurse is caring for a client who has been prescribed clozapine. Which of the following topics should the nurse prepare to discuss with the client?

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?

A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder?

A nurse is providing care for a client who experienced sexual assault. Which of the following communication strategies should the nurse use?

A nurse is preparing a presentation about strategies to decrease health care disparities among vulnerable groups. Which of the following strategies should the nurse include?

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?