The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

Stupor, agitation, muscular rigidity

Hypertension, disorientation, hallucinations

Hypotension, bradycardia, agitation

Hypotension, ataxia, vomiting

Answer and Explanation

The Correct Answer is B

A.   These symptoms are not characteristic of alcohol withdrawal delirium.
B.   Alcohol withdrawal delirium is characterized by symptoms such as hypertension, disorientation, and hallucinations.
C.   Hypotension and bradycardia are not typically associated with alcohol withdrawal delirium. They may be seen in other types of alcohol withdrawal.
D.   These symptoms are not specific to alcohol withdrawal delirium. They may be present in other forms of alcohol withdrawal.

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Correct Answer is C

Explanation

A) Incorrect. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.

B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.

C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.

D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.

A. Administer thiamine intramuscular (IM) B. Assist the client with personal hygiene needs C. Place the client on continuous observation D. Explain milieu therapy

Correct Answer is B

Explanation

A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.

B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.

C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.

D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.

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The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse would monitor for which symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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