Safety is the nursing priority for a client who is at risk for alcohol withdrawal. A care plan for the client who is in withdrawal must include which nursing interventions?
Seizure precautions and vital signs.
Observation for symptoms, vital signs, seizure and fall precautions, medications as ordered.
Suicide precautions because suicide atempts are frequent during withdrawal.
Vital signs and medications as prescribed.
The Correct Answer is B
Choice A reason: Seizure precautions and monitoring vital signs are important but not comprehensive enough for a complete care plan.
Choice B reason: This is the correct choice. It encompasses a broad range of interventions that are critical for a client undergoing alcohol withdrawal, including monitoring for various symptoms, ensuring safety, and administering medications.
Choice C reason: While suicide precautions are important, they are not the only intervention needed for a client in alcohol withdrawal.
Choice D reason: Monitoring vital signs and administering medications are important but do not cover all necessary precautions such as seizure and fall precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Akathisia is characterized by restlessness and a constant urge to move. It is a common side effect of antipsychotic medications.
Choice B reason: Neuroleptic malignant syndrome is a rare but serious reaction to antipsychotic drugs and is not classified as an extrapyramidal symptom.
Choice C reason: Dystonia involves involuntary muscle contractions and spasms, often affecting the head and neck, and is a known extrapyramidal symptom.
Choice D reason: Tardive dyskinesia is marked by repetitive, involuntary movements, typically of the face and extremities, and is an extrapyramidal symptom that can occur after long-term use of antipsychotics.
Choice E reason: Pseudo-parkinsonism mimics symptoms of Parkinson's disease, such as tremors and slowed movement, and is an extrapyramidal side effect of antipsychotic medications.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. The client's belief that "They're out to get me" is indicative of paranoia, a common symptom in schizophrenia.
Choice B reason: This choice is incorrect. Stilted language refers to an unnatural, formal way of speaking, not suspicion or guardedness.
Choice C reason: This choice is incorrect. Pressured speech is rapid and urgent speech, which is not described in the scenario.
Choice D reason: This choice is incorrect. Autistic thinking is associated with autism, not schizophrenia, and does not involve paranoia.
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