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

Answer and Explanation

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.

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Correct Answer is A

Explanation

This is an essential instruction for performing passive ROM exercises safely and effectively. Supporting the extremity above and below each joint helps to prevent injury and provides stability during the exercise. This technique also helps to minimize discomfort and maintain proper alignment of the joint.

Repeat each exercise movement 10 times: This instruction does not provide sufficient guidance on the number of repetitions and may be too general. The number of repetitions will depend on the client's condition and tolerance.

Position the bed at mid-thigh level: This instruction is not necessary for performing passive ROM exercises and may not be feasible in all settings.

Move each joint just past the point of resistance: This instruction can be harmful and may cause injury or pain. The nurse should encourage the family to move the joint gently and smoothly, within the range of motion that is comfortable for the client.

A. Use written signs to assist the client with locating the bathroom. B. Limit the number of choices for the client. C. Use confrontation to manage the client's behavior. D. Provide a stimulating environment for the client.

Correct Answer is B

Explanation

It is important to provide choices for the client, but limit them to two or three options to prevent confusion and decision-making difficulties.

Use visual cues to assist the client with locating the bathroom, such as pictures or color-coded signs instead of written signs.

Avoid using confrontation to manage the client's behavior, as it can increase agitation and aggression. Instead, use redirection and positive reinforcement.

Provide a calm and non-stimulating environment for the client, as overstimulation can lead to confusion and agitation.

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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?

Nursing Test Bank

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