The nurse is assisting in the care of a client in an inpatient mental health facility.

For which of the following manifestations of withdrawal is the client at risk? Select the 4 manifestations of withdrawal for which the client is at risk.

Diaphoresis

Anxiety

Insomnia

Slurred speech

Hyperreflexia

Hypothermia

Answer and Explanation

Correct Answer : A,B,C,E

A. Diaphoresis: Sweating is a common manifestation of opioid and stimulant withdrawal. The client’s recent heroin and methamphetamine use puts them at risk for autonomic hyperactivity, including diaphoresis.

B. Anxiety: Anxiety is a frequent symptom during withdrawal from both opioids and stimulants. The client’s agitation and fear of worsening withdrawal indicate heightened risk for emotional and psychological distress.

C. Insomnia: Sleep disturbances, including difficulty falling or staying asleep, are common during withdrawal from substances such as heroin and methamphetamine. Insomnia contributes to fatigue and irritability during the withdrawal period.

D. Slurred speech: Slurred speech is more indicative of acute intoxication, central nervous system depressant effects, or neurological impairment rather than withdrawal symptoms. It is not expected in opioid or stimulant withdrawal.

E. Hyperreflexia: Increased reflexes can occur during stimulant withdrawal or opioid withdrawal due to central nervous system hyperactivity. The client’s restlessness and autonomic manifestations suggest this risk.

F. Hypothermia: Withdrawal typically causes hyperthermia or temperature instability rather than hypothermia. Low body temperature is not a typical manifestation in opioid or stimulant withdrawal.

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Correct Answer is D

Explanation

A. A client in the dayroom who is screaming at other clients about what is on the television: This behavior is disruptive but does not pose an immediate safety threat to the client or others. The nurse should monitor and intervene as needed, but it is not the highest priority.

B. A client who has bipolar disorder and is continuously pacing at the end of the hall: Pacing may indicate agitation or restlessness, but if the client is not aggressive or threatening, it poses less immediate risk. The nurse should assess for escalation but prioritize clients with potentially dangerous behaviors first.

C. A client who is repeatedly approaching the nurses' station to request medication for their anxiety: While attention to anxiety is important, this behavior does not indicate imminent danger or risk of harm. It can be addressed after attending to clients who may be violent or unsafe.

D. A client who is standing in their room, yelling obscenities, and throwing their clothes: This client is exhibiting aggressive and potentially violent behavior that could escalate to self-harm or harm to others. Ensuring safety and de-escalation for this client takes priority over disruptive or non-threatening behaviors.

A. Hypersensitivity to criticism B. Grandiosity C. Racing thoughts D. Pressured speech

Correct Answer is A

Explanation

A. Hypersensitivity to criticism: Clients with depressive disorders often exhibit low self-esteem and heightened sensitivity to perceived criticism or rejection. This can manifest as emotional distress, withdrawal, or exaggerated responses to minor feedback, which aligns with typical depressive symptoms.

B. Grandiosity: Grandiose thoughts or inflated self-esteem are characteristic of manic or hypomanic episodes, not depressive disorders. Clients experiencing depression typically have diminished self-worth rather than exaggerated confidence.

C. Racing thoughts: Racing thoughts are associated with mania or hypomania, indicating a rapid flow of ideas that is not typical in depressive disorders. Depressed clients are more likely to experience slowed thinking and indecisiveness.

D. Pressured speech: Pressured speech, characterized by rapid and forceful talking, occurs in manic or hypomanic states. Depressive disorders generally involve slowed speech, limited verbal output, or monotone expression rather than pressured speech.

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The nurse is assisting in the care of a client in an inpatient mental health facility. For which of the following manifestations of withdrawal is the client at risk? Select the 4 manifestations of withdrawal for which the client is at risk.

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The nurse is assisting in the care of a client in an inpatient mental health facility.

For which of the following manifestations of withdrawal is the client at risk? Select the 4 manifestations of withdrawal for which the client is at risk.