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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will send you a note in a few weeks.": This response is inappropriate and could blur professional boundaries in the therapeutic nurse-client relationship.
B. "I know you will do well living out in the community.": While supportive, this response assumes the client's future success without addressing their immediate feelings or concerns.
C. "Aren't you excited about being discharged today?": This response is leading and may not reflect the client’s true feelings.
D. "How do you feel about being discharged?": This open-ended question encourages the client to express their emotions and concerns about the transition, which is appropriate in the termination phase of the therapeutic relationship.
Correct Answer is C
Explanation
A. "I have no intention to stop drinking. I like the way it makes me feel.": This is an example of denial but does not strongly indicate a defense mechanism.
B. "I have tried so many times to stop drinking. It is so hard.": This demonstrates acknowledgment of the problem and a desire for change, not a defense mechanism.
C. "I don't really have a problem with alcohol. I've just been having a streak of bad luck lately.": This is an example of rationalization, a defense mechanism where the individual justifies their behavior with excuses.
D. "I really need some help. My drinking is tearing my family apart.": This statement reflects insight and readiness for change, not a defense mechanism.
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