A nurse is collecting data from a client who is receiving treatment for alcohol detoxification. Which of the following findings is the nurse's priority?
Hallucinations
Tremors
Anorexia
Insomnia
The Correct Answer is A
A. Hallucinations. Hallucinations are a sign of severe alcohol withdrawal, such as delirium tremens (DTs), which can be life-threatening and requires immediate medical attention.
B. Tremors. Tremors are a common withdrawal symptom but are not as critical as hallucinations.
C. Anorexia. Loss of appetite is a minor symptom and not life-threatening.
D. Insomnia. Although common in withdrawal, insomnia is not an urgent priority compared to hallucinations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “Disulfiram will prevent my cravings for alcohol.” Disulfiram creates an aversion but does not reduce cravings.
B. "I should expect hand tremors to start less than 24 hours after I stop drinking." Tremors typically begin within 6-24 hours of the last drink.
C. "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage." Thiamine (Vitamin B1), not Vitamin C, is essential to prevent Wernicke’s encephalopathy and other complications.
D. "Withdrawal symptoms should last about 5 to 7 days once they begin." Withdrawal symptoms typically peak in 48-72 hours and subside after 4-5 days, not 7 days.
Correct Answer is ["A","C","D","E"]
Explanation
A. Having a learning disability: Learning disabilities can increase vulnerability due to academic struggles and lower self-esteem.
B. Inadequate sleep at night: While poor sleep can affect mood and behavior, it is not a direct high-risk factor for substance abuse.
C. Substance use within immediate family: Exposure to substance use in the family normalizes such behavior, increasing the risk.
D. Feeling unsafe at home: An unstable or unsafe home environment is a significant risk factor for substance abuse.
E. Fighting with peers at school: Peer conflict can lead to isolation and susceptibility to negative influences like substance use.
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