A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

Tachycardia.

Tremors.

Hallucinations.

Hypotension.

Seizures.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale:

Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.

Choice B rationale:

Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.

Choice C rationale:

Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.

Choice E rationale:

Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.

Choice D rationale:

Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse's approach of sitting with the client and offering simple, direct information is appropriate for a newly admitted client diagnosed with severe depression. This approach allows the nurse to establish a therapeutic rapport and provide the client with essential information in a clear and concise manner. People with severe depression often have difficulty processing complex information, so providing simple and direct information can enhance their understanding and alleviate any feelings of overwhelm.

Choice B rationale:

Explaining the unit policies and answering the client's questions might be overwhelming for someone with severe depression during their initial orientation. People experiencing depression often have difficulties with concentration and retaining information due to cognitive impairment. Presenting them with detailed policies and procedures might increase their anxiety and hinder their ability to absorb the information effectively.

Choice C rationale:

Having the client attend group therapy immediately might not be the best approach for someone with severe depression upon admission. Group therapy could be beneficial later in the treatment process, but initially, the client might not be emotionally ready to engage in group interactions. It's essential to establish a one-on-one therapeutic relationship and provide a stable environment before introducing them to group settings.

Choice D rationale:

Taking the client on a tour of the unit and introducing them to all the staff members on duty might be overwhelming and anxiety-inducing for someone with severe depression. It's crucial to approach the client with sensitivity and respect their emotional state. Introducing them to multiple staff members might increase their social anxiety and make them feel exposed, leading to further distress.

A. Demonstrate genuineness when communicating. B. Focus on the words of the clients. C. Control the pace of establishing the nurse-client relationships. D. Provide sympathy during interactions.

Correct Answer is A

Explanation

Choice A rationale:

Demonstrating genuineness involves being authentic, sincere, and transparent in interactions with clients. This helps build trust by showing that the nurse's intentions and emotions align with their words. Genuineness fosters a sense of safety and openness in the therapeutic relationship.

Choice B rationale:

While focusing on the words of the clients is important, it's not the only factor. Nonverbal cues, emotions, and context also play significant roles in effective communication. Only focusing on words could result in missing important nuances and emotions.

Choice C rationale:

Controlling the pace of the nurse-client relationship contradicts the principle of client-centered care, where the client's readiness and comfort should guide the pace. Pushing the pace might lead to resistance or discomfort, hindering the development of trust.

Choice D rationale:

Providing sympathy involves expressing pity or sorrow for the client's situation. However, empathy, which involves understanding and sharing the client's feelings, is more appropriate. Sympathy might create a sense of pity, while empathy establishes a deeper connection and understanding.

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A nurse on the medical unit is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.).

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