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 D
Explanation
A. This disorder is characterized by sudden, rapid, recurrent motor movements and vocal tics, not slow, writhing movements caused by long-term antipsychotic use.
B. This is a dangerous reduction in white blood cells, typically presenting with fever, sore throat, or infections, not abnormal involuntary movements.
C. Anticholinergic side effects include dry mouth, blurred vision, constipation, urinary retention, not the repetitive, involuntary movements seen here.
D. This condition is a late-onset side effect of long-term use of antipsychotics, especially first-generation drugs like fluphenazine. It presents as grimacing, lip smacking, and slow, writhing movements of the neck and shoulders, consistent with the patient’s symptoms.
Correct Answer is A
Explanation
A. Justice refers to fairness and equality in the distribution of care and resources. The nurse is concerned about whether patients exhibiting similar behaviors (self-mutilation) are being treated consistently and fairly, which directly relates to the principle of justice.
B. Fidelity involves keeping promises and commitments to patients, which is not the primary concern in this scenario.
C. Beneficence involves acting in the patient’s best interest to promote well-being. While relevant to care decisions, the main ethical issue here is fairness between patients.
D. Autonomy involves respecting a patient’s right to make their own decisions, which is not the central issue in comparing the care of two patients.
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