The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Dilated pupils, tachycardia, elevated blood pressure, elation.

Excessive eating, constipation, headache.

Nausea, vomiting, diaphoresis, anxiety, tremors.

Mood lability, poor hand coordination, fever, drowsiness.

Answer and Explanation

The Correct Answer is C

A. Dilated pupils, tachycardia, elevated blood pressure, elation: These symptoms are more typical of stimulant intoxication and do not indicate alcohol withdrawal. They are not consistent with the need for a detox protocol focused on alcohol or other depressants.

B. Excessive eating, constipation, headache: These symptoms are not associated with alcohol or drug intoxication or withdrawal. They do not suggest a need for detoxification medication protocols.

C. Nausea, vomiting, diaphoresis, anxiety, tremors: These are classic signs of alcohol withdrawal and suggest the need for detoxification. These symptoms require immediate intervention to manage withdrawal safely and avoid complications.

D. Mood lability, poor hand coordination, fever, drowsiness: These signs are more indicative of intoxication with substances like sedatives. While concerning, they do not point to alcohol withdrawal, which requires specific detox protocols.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Client exhibits a frequent productive cough: While a productive cough may indicate airway clearance, it does not assess the effectiveness of the incentive spirometer. The primary goal of the incentive spirometer is to improve lung expansion, not to stimulate coughing.

B. Client reports using the incentive spirometer every hour while awake: Regular use of the incentive spirometer is important, but it alone does not fully evaluate its effectiveness. The goal is to improve lung function, and a physical assessment is needed to gauge this.

C. Client's breath sounds are clear to auscultation bilaterally: This is the best indicator of the effectiveness of the incentive spirometer. Clear breath sounds suggest improved lung expansion and ventilation, which is the primary goal of using the device.

D. Client demonstrates proper use of an incentive spirometer: While proper technique is essential for effectiveness, demonstrating correct use does not fully assess whether the desired outcomes are achieved.

A. Palpate the client's suprapubic area for distention. B. Obtain a urine specimen for culture and sensitivity. C. Instruct in effective techniques to cleanse the glans penis. D. Advise the client to maintain a voiding diary for one week.

Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: The symptoms suggest possible urinary retention, which could be a result of benign prostatic hyperplasia (BPH) or another obstruction. Palpating the suprapubic area for distention is important to assess for urinary retention and determine if the bladder is full.

B. Obtain a urine specimen for culture and sensitivity: Although a urinary tract infection can cause urinary symptoms, the client's presentation is more likely indicative of a physical obstruction such as BPH. A culture might be needed later if infection is suspected.

C. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important, especially in older adult men, but this is not the most relevant action for the symptoms described. The focus should be on assessing for possible urinary retention or obstruction.

D. Advise the client to maintain a voiding diary for one week: While a voiding diary may provide useful information for monitoring symptoms over time, the immediate priority is to assess for urinary retention and bladder distention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is C

Explanation

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.

A client returns to the mental health clinic for assistance with an anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. Which action in the treatment plan should the nurse implement?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

The nurse is caring for a client who underwent a right lobectomy for lung cancer 24 hours ago and has a single chest tube on the right side. Which intervention(s) should the nurse plan to implement? Select all that apply.

Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Exhibits The nurse reviews the intake information prior to seeing the client. What finding(s) should the nurse recognize as signs of dehydration that require immediate follow up? Select all that apply.

Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.