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 A
Explanation
A. This statement accurately describes a key aspect of somatic symptom disorder. Individuals with this disorder experience real physical symptoms, but these symptoms are primarily driven by psychological or emotional factors rather than underlying physical causes.
B. Suicidal ideation is not a defining characteristic of the disorder. Somatic symptom disorder primarily involves persistent and distressing physical symptoms along with excessive thoughts, feelings, or behaviors related to those symptoms.
C. Somatic symptom disorder is not characterized by malingering or intentionally fabricating symptoms. Individuals with this disorder genuinely experience physical symptoms that cause distress and impairment
D. There are effective treatment approaches available, including cognitive-behavioral therapy (CBT), psychotropic medications for co-occurring conditions such as depression or anxiety, and supportive therapies that address underlying psychological factors
Correct Answer is C
Explanation
C. Stalking involves persistent and unwanted attention or behavior directed towards a specific individual, causing fear, distress, or concern for their safety. Stalking behaviors may include following the victim, surveillance, unwanted communication (such as letters, emails, or messages), vandalism, or leaving gifts or items at the victim's location
A. Bullying involves aggressive behavior or intentional harm directed toward another person, typically in a repeated or habitual manner.
B. Abandonment refers to the act of deserting or leaving someone or something behind, often without adequate support or care.
D. Assault involves the intentional infliction of physical harm or injury on another person, or the threat of such harm, causing fear or apprehension of imminent harm.
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