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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Suspended from school several times in the past year.
Choice A rationale:
The client's father's recent death (Choice A) is not a typical expected assessment finding of conduct disorder. While emotional disturbances can be associated with conduct disorder, the primary characteristics involve behavioral issues rather than reactions to significant life events.
Choice B rationale:
Adhering strictly to routines (Choice B) is not a common expected assessment finding of conduct disorder. Conduct disorder is characterized by patterns of defiant and disruptive behaviors, not necessarily a rigid adherence to routines.
Choice C rationale:
Suspended from school several times in the past year (Choice C) aligns with the expected assessment findings of conduct disorder. Conduct disorder often involves aggressive behavior towards others, violation of rules, and disregard for the rights of others, which can lead to disciplinary actions such as school suspensions.
Choice D rationale:
Experiencing frequent facial tics (Choice D) is not a typical expected assessment finding of conduct disorder. Facial tics are associated with conditions like Tourette's syndrome or other tic disorders, not conduct disorder.
Correct Answer is D
Explanation
Answer is d. Situational.
a. Maturational crisis: This type of crisis occurs in response to life transitions or developmental stages, such as marriage, parenthood, retirement, or aging. It involves challenges related to adjusting to new roles, responsibilities, or expectations. However, the client's denial of a new HIV diagnosis and refusal of treatment do not align with the characteristics of a maturational crisis, as it pertains to planned life events rather than unexpected health crises.
b. Adventitious crisis: Adventitious crises are caused by events that are unplanned, unexpected, and often traumatic, such as natural disasters, accidents, or crimes. These crises can affect individuals, families, or communities and may result in significant psychological distress and disruption. However, the client's denial of an HIV diagnosis does not fit the criteria for an adventitious crisis, as it is a personal health issue rather than an external event affecting a broader population.
c. Internal crisis: While internal struggles and conflicts can contribute to a person's overall crisis experience, "internal crisis" is not a recognized category within the context of nursing crises. Internal factors such as psychological distress, unresolved trauma, or maladaptive coping mechanisms may exacerbate crisis situations, but they are typically addressed within the framework of other crisis categories such as situational, maturational, or existential crises.
d. Situational crisis: Correct. A situational crisis arises from an external event or situation that the individual finds overwhelming, threatening, or challenging to cope with. In this scenario, the client's denial of their HIV diagnosis and refusal of treatment represent a situational crisis as it stems from the unexpected news of their health condition. The client's perception of the diagnosis as threatening or inconceivable leads to emotional distress and maladaptive coping mechanisms, which can hinder their ability to accept and manage their medical condition effectively.
In summary, the correct answer is d because the client's denial of their HIV diagnosis and refusal of treatment align with the characteristics of a situational crisis, which arises from an external event that the individual perceives as overwhelming or threatening. Understanding the nature of the crisis can guide the nurse in providing appropriate support, education, and intervention to help the client navigate through this challenging time and make informed decisions regarding their healthcare.
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