A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestation should the nurse include in the reaching? (Select all that apply.)
Nystagmus
Illusions
Polyphagia
Tremors
Seizures
Correct Answer : B,D,E
A. Nystagmus: Nystagmus is not a typical manifestation of alcohol withdrawal. It is more commonly associated with intoxication or neurological conditions. Therefore, it is not included in the effects of alcohol withdrawal.
B. Illusions: Illusions (misinterpretations of external stimuli) are common during alcohol withdrawal, especially in severe cases such as withdrawal delirium (delirium tremens). Clients may misinterpret shadows or objects as threatening.
C. Polyphagia: Polyphagia (excessive eating) is not a recognized manifestation of alcohol withdrawal. Clients with withdrawal may experience nausea or a lack of appetite rather than an increased appetite.
D. Tremors: Tremors, often called "the shakes," are one of the most common early signs of alcohol withdrawal. They usually begin within hours after alcohol cessation.
E. Seizures: Seizures, specifically generalized tonic-clonic seizures, are a serious complication of alcohol withdrawal. They can occur within 6–48 hours after the last drink and are part of alcohol withdrawal syndrome.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discuss the problem in a community meeting with the other clients on the unit present.
While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.
B. Escort the client to her room each time the nurse observes the client socializing with other clients.
This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.
C. Talk to the client and identify the specific limits that are required of the client's behavior.
This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.
D. Tell the other clients to ignore the client's lies.
While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.
Correct Answer is C
Explanation
While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.
B) "Your doctor is a man, so it seems like this should not be a problem."
Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.
C) "I can review the assignments and arrange for a female nurse to care for you."
Explanation:
Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.
D) "The nurse assigned to care for you is very capable and cares for other women in this situation."
While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.
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