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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dental erosion can occur due to conditions like gastroesophageal reflux disease (GERD) or frequent vomiting, but it is not a characteristic feature of anorexia nervosa.
B. Hyperactive bowel sounds are not specific to anorexia nervosa and may be seen in various gastrointestinal disorders.
C. Hypertension is not a common finding in individuals with anorexia nervosa. In fact, hypotension (low blood pressure) is more commonly observed due to decreased cardiac output related to malnutrition and electrolyte imbalances.
D. bradycardia in a client with a new diagnosis of anorexia nervosa. Bradycardia (abnormally slow heart rate) is a common cardiovascular manifestation in individuals with anorexia nervosa. It is often a result of the body's adaptive response to conserve energy due to severe malnutrition and reduced caloric intake.
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.
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