The nurse is assessing patients for impending alcohol withdrawal. The nurse assesses the patient with which of the following conditions as a priority?
Reporting muscle aches and frequent stumbling
Dozing off in chair and not recognizing staff
Pulse. 118 beats/min; and BP 160/90
Pulse, 58 beats/min; and BP 100/60
The Correct Answer is C
A. While these symptoms can be associated with alcohol withdrawal, they are not as indicative of an immediate medical emergency as tachycardia and hypertension.
B. While these symptoms may suggest cognitive impairment, they are not as indicative of impending alcohol withdrawal syndrome as tachycardia and hypertension.
C. Alcohol withdrawal can lead to various physiological changes, including increased heart rate and blood pressure. A pulse of 118 beats/min and a blood pressure of 160/90 indicate a significant increase in both vital signs, which could be a sign of impending alcohol withdrawal syndrome.
D. These vital signs are within normal limits and do not indicate a significant risk of alcohol withdrawal syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. In Korean culture, silence and avoiding eye contact can be seen as signs of respect and deference, especially towards individuals perceived as having authority or expertise. Therefore, the patient's behavior is likely not a sign of dissatisfaction or discomfort, but rather a cultural expression of respect for the nurse.
B. While it is possible for the patient to be dissatisfied with his care, the nurse should not assume this based solely on his behavior. It's important to consider cultural factors and use other communication strategies to assess the patient's needs and concerns.
C. This is not necessarily the case. The patient may simply be uncomfortable speaking up or asking questions in a language that is not his native tongue.
D. While it is possible for the patient to be uncomfortable discussing personal matters, the nurse should not assume this based solely on his behavior. It's important to consider cultural factors and use other communication strategies to assess the patient's needs and concerns.
Correct Answer is B
Explanation
A. This question focuses on future preparedness and may come off as presumptive or confrontational. It doesn't directly address the patient's personal feelings or experiences but rather implies an expectation about how they and their spouse will handle the situation over time. This might not encourage an open discussion about the patient's personal perception of their sexuality.
B. This question directly addresses how the sexual dysfunction affects the patient’s intimate relationship, which can provide insight into the patient's personal perception and emotional response to the problem. It allows the patient to discuss how their condition affects their intimate life and personal feelings, promoting a deeper understanding of their experience.
C. This question focuses on coping mechanisms and may shift the focus away from the patient's personal feelings to how both partners are managing the situation. While it can provide useful
information about coping strategies, it may not fully explore the patient’s individual perceptions and
emotional impact.
D. This question explores relational issues caused by the sexual dysfunction. It might elicit information about interpersonal conflicts or challenges but might not fully capture the patient’s personal feelings about their sexuality or how the dysfunction specifically impacts their self-perception and intimate experiences.
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