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 statement "You are feeling very depressed. I felt the same way when I decided to leave my husband." is a non-therapeutic statement that demonstrates sympathy. The nurse is sharing personal experiences, which can shift the focus from the client's feelings to the nurse's own experiences.

Choice B rationale:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you." is a therapeutic response that offers support and empathy without diverting the focus to the nurse's experiences. The nurse's willingness to sit with the client is a positive aspect of this response.

Choice C rationale:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is a therapeutic response that acknowledges the client's feelings, offers support, and invites further conversation. This response encourages the client to express themselves.

Choice D rationale:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" acknowledges the client's difficulties but immediately offers medication as a solution. While medication can be a valid option, it's important to prioritize open communication and emotional support before suggesting medication.

A. Instruct the client to sit down and stop pacing. B. Have a staff member escort the client to her room. C. Walk with the client at a gradually slower pace. D. Allow the client to pace alone until physically tired.

Correct Answer is C

Explanation

The correct answer is choice C. Walk with the client at a gradually slower pace.

Choice A rationale:

Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.

Choice B rationale:

Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.

Choice C rationale:

Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.

Choice D rationale:

Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

Correct Answer is A

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

During a family group therapy session, the nurse overhears the client telling her daughter, "You need to do better in school so I can love you as much as I love your brother." According to Warren, this statement discourages the development of positive self-esteem by hindering which parenting focus?

The nurse is assessing a client in group therapy on which type of techniques for modifying behaviors would be most appropriate. The nurse has decided to use covert sensitization. Which of the following statementbest describes this type of therapy?

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply).

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is caring for a client who is withdrawing from opioids. Which of the following medications would the nurse prepare to administer?