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 A
Explanation
Choice A rationale:
Similar to the explanation in , this statement requires intervention. It reflects a judgmental and prescriptive approach, which is not conducive to a therapeutic conversation. It implies that the nurse knows what the client should do, undermining the client's autonomy and self-discovery process.
Choice B rationale:
Recognizing that relationship difficulties are stressful and require effort to resolve is a valid and supportive statement. It acknowledges the challenges the client is facing and does not impose a specific solution.
Choice C rationale:
Suggesting the development of a communication plan is a proactive and therapeutic response. It empowers the client to work collaboratively toward improving their marital situation.
Choice D rationale:
Encouraging the client to share more about their concerns promotes open communication and allows the nurse to better understand the client's perspective. This response is client-centered and supportive.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Phase IV is not a recognized phase in the cycle of battering. Typically, the cycle of battering consists of three phases: tension-building, acute battering, and honeymoon phase. Each phase has distinct characteristics.
Choice B rationale: Phase I, the tension-building phase, is characterized by increased tension, irritability, and frustration in the abuser. The victim may sense the abuser's declining tolerance for frustration, leading them to try to avoid confrontation by staying out of the abuser's way.
Choice C rationale: Phase III is the honeymoon phase, where the abuser may apologize, show remorse, and be affectionate. The victim may feel hopeful for change. However, this does not match the described behavior of increasing frustration and anger with quick apologies.
Choice D rationale: This is a duplicate of Choice B. As previously stated, Phase I, the tension-building phase, involves the buildup of tension and irritability in the abuser, leading the victim to try to stay out of the abuser's way to avoid conflict.
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