A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect?
Hypertension
Constipation
Polyuria
Bradycardia
The Correct Answer is A
Alcohol withdrawal can often lead to an increase in blood pressure. The autonomic nervous system becomes hyperactive during withdrawal, resulting in increased sympathetic activity, which can elevate blood pressure.
Constipation is not typically associated with alcohol withdrawal. However, chronic alcohol use can affect the gastrointestinal system and lead to digestive issues, including diarrhea or gastrointestinal bleeding.
Polyuria, which refers to excessive urination, is not a typical manifestation of alcohol withdrawal. However, alcohol use can affect fluid balance and lead to changes in urination patterns.
Bradycardia, or a slow heart rate, is not a common manifestation of alcohol withdrawal. Instead, tachycardia (an increased heart rate) is more commonly observed during withdrawal due to the hyperactivity of the autonomic nervous system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.
Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.
Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.
Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.
Correct Answer is B
Explanation
A.Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B.Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C.Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
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