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. Calling the poison control center is the immediate and most important action to take in cases of potential poisoning or chemical exposure. Poison control centers have trained professionals who can provide immediate guidance on how to assess the situation, provide first aid if necessary, and determine if further medical evaluation or treatment is needed.

A. While assessing the parent's understanding of emergency measures is important, it may not be the first action to take in this situation.

B. Providing information about the risks of chemical exposure can be helpful for prevention, but it may not be the first action to take when there is uncertainty about whether the child has ingested a harmful substance.

D. While securing cleaning supplies to prevent future incidents is important, it is not the first action to take when there is concern about a potential ingestion.

A. Relapses signal failure of the abstinence plan, and the plan must be changed. B. Relapses may indicate that the client has very little willpower. C. Relapses should be expected and be looked at as an opportunity. D. Relapses are rare and unlikely to occur.

Correct Answer is C

Explanation

C. This statement emphasizes a crucial aspect of relapse prevention in substance use disorder treatment. Relapses are common in the recovery process and should not be seen as failures but rather as opportunities for learning and growth.

A. Relapses are common in the course of recovery from substance use disorders and do not necessarily indicate failure.

B. Relapse is not solely a result of willpower or lack thereof. It involves various factors, including biological, psychological, social, and environmental influences.

D. Relapses are common in the journey of recovery from substance use disorders, especially in the early stages when individuals are still learning to navigate triggers and develop coping strategies.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home care nurse is speaking with a parent who saw their child playing with cleaning supplies. The parent is not sure if the child ingested anything. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is discussing relapse potential with a group of clients and their families. The nurse should include which of the following statements about relapse prevention?

Correct Answer is C

Explanation

A nurse is providing dietary teaching to a client who has been diagnosed with Alzheimer's disease about including foods to decrease the progression of the disease. Which of the following foods should the nurse recommend?

A nurse is caring for a client who is inquiring about the use of herbal remedies in treating manifestations of mental illness. 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 discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?

A nurse is caring for a client who has been diagnosed with schizophrenia and appears confused and has distortions in their thinking and speech patterns. Which of the following is the priority nursing intervention for this client?

A nurse is caring for a client who frequently breaks their arms and other bones on purpose. The nurse understands that the client likely has which diagnosis?

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?