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 A
Explanation
A. Determining if the client has psychotic thinking.
Explanation: The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
Correct Answer is ["2"]
Explanation
The nurse should administer 2 tablets of olanzapine 10 mg orally-disintegrating tablets per dose.
Here's the calculation:
20 mg (desired dose) ÷ 10 mg (strength of each tablet) = 2 tablets
So, the nurse should administer 2 tablets of olanzapine 10 mg orally-disintegrating tablets per dose.
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