Nokea
The nurse is caring for a client who presented to the ED with a blood alcohol level of 208 mg/dL. The client states that his last drink was about 8 hours ago. He exhibits coarse tremors of the hands, anxiety, and elevated blood pressure. Which of the following would the nurse expect if his condition progresses to withdrawal delirium? Select all that apply.
- A. fever of 100°F to 103°F
- B. increased appetite, especially for sweets
- C. excessive sleeping of 14 hours or more daily
- D. onset of delirium 12 to 24 hours after the last drink
- E. onset of delirium 48 to 72 hours after the last drink
- F. disorientation and fluctuating levels of consciousness
Correct Answer: A,E,F
Rationale: Withdrawal delirium typically includes fever, disorientation, and fluctuating consciousness, with onset 48-72 hours after the last drink. Increased appetite or excessive sleeping are not typical.
You may also like to solve these questions
The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?
- A. Staying with the client
- B. Distracting the client with television
- C. Interpreting the arterial blood gas report
- D. Encouraging the client to cough and breathe deeply
Correct Answer: A
Rationale: Staying with the client has a twofold benefit. First, it relieves the anxiety of the dyspneic client. In addition, the nurse must stay with the client to observe respiratory status after the application of the occlusive dressing. It is possible that the dressing could convert the open pneumothorax to a closed (tension) pneumothorax, which would result in a sudden decline in respiratory status and a mediastinal shift. If this occurs, the nurse is present and able to remove the dressing immediately. Option 2 is nontherapeutic. Interpreting the arterial blood gas report and promoting coughing and deep breathing have no immediate benefits for the client who is in distress.
The nurse obtains an electrocardiogram (ECG) rhythm strip for an adult client who is anxious about the results. The ECG shows that the heart rate is 90 beats per minute. Which statement should the nurse make to the client to relieve anxiety?
- A. The rate is normal.
- B. There is no need to worry.
- C. A slower heart rate is preferred.
- D. Medication specific to the problem will be prescribed.
Correct Answer: A
Rationale: A normal adult resting pulse rate ranges between 60 and 100 beats per minute; therefore, the rate is normal. The nurse would not tell a client not to worry. Options 3 and 4 indicate that the ECG is abnormal.
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
A client has been prescribed imipramine. The nurse notifies the primary health care provider if which adverse effect to the medication is noted?
- A. Increased appetite
- B. Increased drowsiness
- C. Reported decrease in anxiety
- D. Increased sense of well-being
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant that is used to treat various forms of depression and anxiety. The client is also often in psychotherapy while prescribed this medication. Adverse effects to report to the primary health care provider include drowsiness, lethargy, and fatigue. Expected effects of the medication include an increased appetite and time spent sleeping, a reduced sense of anxiety, and an improved sense of well-being.
The nurse on the cardiac unit notes that a client recovering from a myocardial infarction appears worried and irritable. The client says, 'I am worried about my business. I run a restaurant and am used to working 70 hours a week. I am worried about whether I will be able to handle the stress once I am back there.' Which response by the nurse is best?
- A. Give the client a list of complementary therapies related to relaxation and say, 'Pretend this is a menu. Which of these would you like to order for yourself?'
- B. You might find it interesting to attend the cardiac cooking class the dietitian gives before you are discharged.
- C. Who is supposed to be taking care of the restaurant while you are here in the hospital?
- D. Hand the client the television control and say, 'Sometimes when I have a lot on my mind, I watch a movie. It makes me feel better.'
Correct Answer: A
Rationale: Providing a list of relaxation therapies directly addresses the client’s stress concerns and empowers them to choose coping strategies, aligning with their expressed worries about returning to a high-stress job. Other options are less relevant to stress management.