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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.
Correct Answer is A
Explanation
A. Lithium carbonate is a medication commonly used to treat bipolar disorder. Symptoms of lithium toxicity can include nausea, vomiting, diarrhea, muscle weakness, tremors, and flu-like symptoms. If a client is experiencing these symptoms after taking lithium carbonate, it could indicate lithium toxicity
B. Lithium is a mood stabilizer, and tolerance, in the sense of needing increasing doses to achieve the same effect, is not commonly observed.
C. Suddenly stopping lithium carbonate can lead to withdrawal symptoms, but the symptoms described— nausea, diarrhea, muscle weakness, and tremors—are more indicative of toxicity rather than withdrawal.
D. Tyramine is a compound found in certain foods and beverages, and interactions between tyramine-rich foods and certain medications, such as monoamine oxidase inhibitors (MAOIs), can lead to hypertensive crises. However, lithium carbonate is not known to have interactions with tyramine-rich foods.
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