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 C
Explanation
A. Anger is a common emotion in psychiatric patients but is less predictive of suicide risk.
B. Elation may occur in some mood disorders but is not strongly associated with imminent suicide risk.
C. Hopelessness is the feeling most strongly correlated with suicidal ideation and attempts, making it a key predictor for elevated suicide risk.
D. Sadness is a symptom of depression but alone does not reliably predict suicide risk without accompanying hopelessness.
Correct Answer is A
Explanation
A. Haloperidol, a typical antipsychotic, commonly causes extrapyramidal side effects (EPS) such as muscle stiffness, rigidity, tremors, and sedation, which can make patients feel “robotic.”
B. Headache, watery eyes, and runny nose are not typical side effects of haloperidol; they are more consistent with allergy or upper respiratory symptoms.
C. Mild fever, sore throat, and skin rash could indicate a serious reaction such as agranulocytosis, which is rare and more common with atypical antipsychotics like clozapine.
D. Sweating, nausea, and diarrhea are not primary side effects of haloperidol; they may occur with other medications or conditions but are not typical EPS.
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