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. Mild anxiety usually presents with slight discomfort, restlessness, or irritability, and the client remains able to focus and problem-solve.

B. Severe anxiety is characterized by physical symptoms such as chest pain, headache, shortness of breath, and a preoccupation with specific concerns (e.g., personal problems) that limit the client’s ability to focus on other matters.

C. Panic involves sudden, intense terror or dread, often accompanied by inability to communicate or function, and may include distorted perceptions or irrational behavior. The client in this scenario can still verbalize concerns.

D. Moderate anxiety causes narrowing of attention and some tension or restlessness, but the physical manifestations and preoccupation in this scenario indicate a more severe level.

A. communication disorder. B. Attention Deficit Hyperactive Disorder (ADHD). C. intellectual development disorder. D. stereotypic movement disorder.

Correct Answer is B

Explanation

A. Communication disorders involve difficulties with speech, language, or communication (e.g., stuttering, limited vocabulary). The main problem here is hyperactivity, not speech/language impairment.

B. ADHD is characterized by inattention, hyperactivity, and impulsivity. Behaviors such as being in constant motion, excessive talking, lack of sustained interest in activities, and getting up early with energy are hallmark signs of hyperactive/impulsive type ADHD.

C. Intellectual development disorder (formerly mental retardation) involves below-average intellectual functioning and impaired adaptive skills, not constant hyperactivity and excessive talking.

D. Stereotypic movement disorder is repetitive, purposeless motor behavior (e.g., hand flapping, head banging), not generalized hyperactivity and impulsivity.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state. "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?

Correct Answer is B

Explanation

The parent of a 6-year-old says. "My child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me." The child's behavior is most consistent with diagnostic criteria for

Correct Answer is B

Explanation

An elderly patient is admitted with delirium secondary to a urinary tract infection. "The family asks whether the patient will recover?" What would be the nurses' best answer?

A patient experiences a sudden episode of severe anxiety. Which medication would be the expected drug to be given to help with the sudden episode of severe anxiety?

What physical assessment finding is noticeable in a patient who has a history of bulimia?

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action should the staff take initially to prevent this issue?

The nurse expects which medication to be prescribed to maintain abstinence to a patient with an addiction to either alcohol or opioids?

Which action by a psychiatric nurse best applies the ethical principle of autonomy?

A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response.

A patient insistently states, "I can decipher codes of DNA just by looking at someone." Which problem is evident?