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. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.

A. cannot answer the nurse when spoken to. B. may need complete supervision when performing hand hygiene. C. is allowed to use safety scissors with adult guidance. D. follows directions independently when given an assignment.

Correct Answer is B

Explanation

B. Children with IDD often require additional support and supervision in performing daily tasks, including personal hygiene routines like handwashing. Depending on the specific needs and abilities of the child, they may require varying levels of assistance and supervision.
A. Communication abilities can vary widely among children with IDD, and many may be able to understand and respond to simple questions or instructions, albeit with some difficulty.
C. Safety scissors are specifically designed for children to use safely, with features such as blunt tips and plastic blades to minimize the risk of injury. Allowing a child with IDD to use safety scissors with adult guidance can promote independence while ensuring safety.
D. Children with IDD often face challenges in following directions and completing tasks independently, particularly those with lower IQ scores.

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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

The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

Correct Answer is C

Explanation

A nurse is caring for a 10-year old child with Intellectual Developmental Disorder who has an IQ of 45. Which child capability would the nurse expect to observe? The child:

Correct Answer is B

Explanation

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