The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

orient to reality.

identify social supports.

replace fluids.

apply restraints.

Answer and Explanation

The Correct Answer is C

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

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Correct Answer is C

Explanation

C. This statement raises significant concern for possible emotional or psychological abuse. Comparing the child unfavorably to siblings and implying that the child is not as "good" as others could indicate a pattern of emotional maltreatment.
A. This statement does not raise suspicion of child abuse. It merely describes the child's intelligence and does not provide any indication of potential abuse.
B. it is possible for children to sustain injuries due to clumsiness or accidents but this statement alone does not necessarily raise suspicion of child abuse.
D. This statement, on its own, does not necessarily indicate child abuse.

A. Lability of mood B. Hypervigilance C. Constricted pupils D. Increased respirations

Correct Answer is C

Explanation

C. Constricted pupils, also known as miosis, are a classic sign of opioid intoxication. Opioids act on opioid receptors in the brainstem, which can lead to pupillary constriction.
A. Lability of mood refers to rapid and unpredictable changes in mood, which is not a typical finding in opioid intoxication.
B. Hypervigilance is not typically associated with opioid intoxication. Instead, opioid intoxication tends to cause CNS depression, leading to symptoms such as drowsiness, sedation, and impaired consciousness.
D. Opioid intoxication typically causes respiratory depression rather than increased respirations. Opioids depress the central respiratory drive, leading to shallow, slow, or irregular breathing patterns.

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The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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