A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, and diaphoretic and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient
is attempting to obtain attention by manipulating staff.
has symptoms of alcohol withdrawal delirium.
may have sustained a head injury before admission.
is having an acute psychosis.
The Correct Answer is B
A. The patient’s symptoms are physiological and neurological, not intentional behaviors for attention.
B. Alcohol withdrawal delirium (delirium tremens) typically occurs 48–72 hours after the last drink and includes tremors, agitation, anxiety, diaphoresis, tachycardia, hallucinations, and nightmares—all present in this patient.
C. Although head injury can cause confusion and agitation, the timing of symptoms following alcohol withdrawal aligns more closely with delirium tremens.
D. Acute psychosis can present with hallucinations, but in this case, the onset following alcohol cessation and accompanying autonomic hyperactivity point toward alcohol withdrawal delirium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessing lung sounds and extremities is not a priority in this context unless there are signs of fluid overload or other complications; it does not address the psychosocial aspect of anorexia recovery.
B. Positive reinforcement encourages the patient’s healthy behaviors and progress, helping to build motivation and self-esteem during the challenging refeeding process. Recognizing the patient’s achievement supports therapeutic engagement and adherence to treatment goals.
C. Immediately establishing a higher weight gain goal may increase anxiety or pressure on the patient, potentially undermining adherence and progress. Goals should remain realistic and individualized.
D. Suggesting aerobic exercise is inappropriate at this stage of refeeding, as excessive activity can interfere with weight restoration and may reinforce disordered behaviors.
Correct Answer is C
Explanation
A. Buspirone – This anxiolytic does not typically cause significant anticholinergic effects.
B. Lithium – Common side effects include tremor, polyuria, and mild gastrointestinal upset, not prominent anticholinergic effects.
C. Imipramine, a tricyclic antidepressant, has strong anticholinergic properties, leading to dry mouth, blurred vision, mydriasis, constipation, and urinary retention.
D. Risperidone – An atypical antipsychotic; anticholinergic effects are minimal compared to tricyclic antidepressants.
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