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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Antipsychotics are used for psychosis (e.g., schizophrenia, delusions, hallucinations), not for acute anxiety.

B. Benzodiazepines (e.g., lorazepam, diazepam, alprazolam) are the treatment of choice for acute anxiety or panic attacks because they act quickly (within minutes to hours) by enhancing GABA neurotransmission, providing rapid relief.

C. Mood stabilizers (e.g., lithium, valproate) are used in bipolar disorder, not for acute situational anxiety.

D. Tricyclic antidepressants (e.g., amitriptyline) are used for long-term management of depression and some anxiety disorders, but their onset is delayed (2–6 weeks), making them ineffective for acute anxiety.

A. The legal requirement for client confidentiality ceases if the client is deceased." B. "Providers are required to warn individuals if the client threatens harm." C. "Health care workers are not required to answer a court's requests for information about a client's disclosure." D. "Staff members are required to divulge information to attorneys if they call for information."

Correct Answer is B

Explanation

A. Confidentiality does not end when a client dies; healthcare professionals are still required to protect the privacy of medical records and disclosures.

B. This reflects the "duty to warn" principle (Tarasoff ruling), which legally obligates providers to take reasonable steps to protect identifiable individuals if a client poses a threat of harm. This is a recognized exception to confidentiality.

C. Healthcare workers must comply with court orders or subpoenas requesting medical information. Refusing is not legally permissible.

D. Attorneys do not automatically have access to client information; a legal order is required. Confidentiality is not broken based on an attorney’s request alone.

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Naxlex Comprehensive Predictor Exams

A patient has acute anxiety related to an automobile accident 2 hours ago. The nurse should teach the patient about medication from which group?

Correct Answer is B

Explanation

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?

Correct Answer is B

Explanation

Which measure would be considered a form of primary prevention for suicide?

A health teaching plan for a patient taking lithium should include instructions to

Which scenario demonstrates a dissociative fugue?

A child diagnosed with ADHD shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior?

A newly hospitalized patient experiencing psychosis says. "Red chair out town board." Which term should the nurse use to document this finding?

A student says, "Before taking a test. I feel very alert and a little restless." The nurse can correctly assess the students experience as

A patient with acute depression states, "God is punishing me for my past sins." What is the nurse's most therapeutic response?

A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated as needed for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?