Nokea
The nurse is completing the admission of a client who is seeking treatment for alcoholism. He tells the nurse that the last time he had any alcohol to drink was at 10:00 AM before he left for the hospital. The nurse closely monitors the client. Which of the following would lead the nurse to suspect that the client is experiencing stage 1 of alcohol withdrawal syndrome? Select all that apply.
- A. Slight diaphoresis
- B. Hand tremors
- C. Intermittent confusion
- D. Heart rate of 135 beats/min
- E. Normal blood pressure
Correct Answer: A,B,E
Rationale: Stage 1 alcohol withdrawal (6?24 hours post-last drink) includes slight diaphoresis (A), hand tremors (B), and normal blood pressure (E). Intermittent confusion (C) and heart rate of 135 (D) are more typical of later stages like delirium tremens.
You may also like to solve these questions
A nurse is talking with a 57-year-old client who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit. It is 5:00 AM, and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that basically describes how her nursing supervisor came to visit and gave it to her to wear so she?d remember to get well. The nurse suspects that the client may be experiencing which of the following?
- A. Wernicke?s syndrome
- B. Delirium tremens
- C. Korsakoff?s psychosis
- D. Malignant hyperthermia
Correct Answer: C
Rationale: The client?s confabulation (fabricated story about the stethoscope) and insomnia suggest Korsakoff?s psychosis (C), a chronic condition from alcohol-related thiamine deficiency causing memory deficits. Wernicke?s syndrome (A) involves ataxia and confusion, delirium tremens (B) includes severe autonomic symptoms, and malignant hyperthermia (D) is unrelated to alcohol.
A 52-year-old male client who has a history of alcohol dependence is admitted to a detoxification unit. He has tremors, he is anxious, his pulse has risen from 98 to 110 beats/min, his blood pressure has risen from 140/88 to 152/100 mm Hg, and his temperature is six tenths of a degree above normal. He is slightly diaphoretic. Which nursing diagnosis would be the priority?
- A. Disturbed Thought Processes
- B. Risk for Injury
- C. Ineffective Coping
- D. Ineffective Denial
Correct Answer: B
Rationale: The client?s symptoms (tremors, anxiety, elevated vitals, diaphoresis) indicate early alcohol withdrawal, making Risk for Injury (B) the priority due to potential progression to seizures or delirium. Thought processes (A), coping (C), and denial (D) are secondary concerns.
A nurse is obtaining a history from a client who drinks about 6 cups of coffee and several diet cola drinks per day. The client states, I just cut down my coffee and soda intake to one per day. Which of the following would the nurse most likely expect to assess? Select all that apply.
- A. Headache
- B. Fatigue
- C. Yawning
- D. Flushing
- E. Diuresis
Correct Answer: A,B,C
Rationale: Abrupt reduction in caffeine intake can cause withdrawal symptoms like headache (A), fatigue (B), and yawning (C) due to CNS and adenosine receptor changes. Flushing (D) and diuresis (E) are not typical caffeine withdrawal symptoms.
A client tells the nurse that he is committed to trying to quit smoking. When teaching the client about smoking cessation, which of the following would the nurse include?
- A. Success usually involves more than one type of intervention.
- B. Relapse is fairly rare within the first year of quitting.
- C. Ear acupressure is a highly proven method for quitting.
- D. Education is key for smoking cessation.
Correct Answer: A
Rationale: Smoking cessation success typically requires multiple interventions (A), such as behavioral therapy, medications, and support groups. Relapse is common in the first year (B), ear acupressure (C) lacks strong evidence, and education alone (D) is insufficient.
A client is receiving methadone maintenance therapy. After teaching the client about this treatment, the nurse determines that the teaching was successful when the client states which of the following?
- A. I can have a glass of wine with dinner if I choose.
- B. I should eat small frequent meals if I get nauseated.
- C. I should take the drug on an empty stomach.
- D. I might experience diarrhea with this drug.
Correct Answer: B
Rationale: Methadone can cause nausea, and eating small, frequent meals (B) helps manage this side effect. Alcohol (A) should be avoided, methadone is taken without regard to food (C), and constipation, not diarrhea (D), is a common side effect.