Test Prep
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A client with substance abuse is admitted to the mental health unit. Whichaction should be implemented by the nurse, and not delegated to a
%i.%!.%#.%$.%%.unlicensed assistive personnel (UAP)?As part of a comprehensive assessment, the nurse should assess the client forpast and present alcohol, tobacco, prescription drug, over-the-counter drug,and illicit drug use (C). The UAP is qualified to provide the client with menus fordietary selection (A), clarify unit policies including visiting hours and telephoneuse (B), obtain vital signs and orient the client to the unit (D).Which action should the nurse implement first for a client experiencingalcohol withdrawal?The nurse is caring for a client who was admitted for alcohol detoxification2 days ago. Which finding is most critical for the nurse to report to thehealthcare provider?
%!.!.#.$.%.%#.this critical syndrome of alcohol withdrawal, manifested as global confusion andan inability to recognize family members (B), is life-threatening and requiresemergency medical intervention. The early signs of withdrawal (A) developwithin a few hours after cessation or reduction of alcohol (ethanol) intake; thesigns peak after 24 to 48 hours (C and D) and then rapidly and dramaticallydisappear, unless the withdrawal progresses to alcohol withdrawal delirium.During a one-to-one interaction, a male client describes the sadness heexperienced when his mother died. Suddenly, the nurse begins to thinkabout her grandmother's death. As a result, the nurse asked the client todescribe his thoughts when he learned of his own mother's illness. What isthe nurse doing?
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60. What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
A. Risk for injury R/T central nervous system stimulation
B. Disturbed thought processes R/T tactile hallucinations
C. Ineffective coping R/T powerlessness over alcohol use
D. Ineffective denial R/T continued alcohol use despite negative consequences
60. Nurse Stacy is caring for Mr. Moore, who is in acute alcohol withdrawal. She should
anticipate the provider will prescribe which of the following medications?
Lorazapam
60. Nurse Stacy is planning care for Mr. Moore. Which of the following nursing interventions is
appropriate for a client in alcohol withdrawal?
Promote a low stimulation environment
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following
findings should the nurse expect?
A) Muscle aches and chills
B) Fatigue and depression
C) Anxiety and diaphoresis
D) Arrhythmia and respiratory depression
69. A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client
decides to attend an Alcoholics Anonymous meeting. What is a basic principle of this group?
1 Spouses should attend Al-Anon meetings
2 A commitment to permanent abstinence must be made
3 Amends must be made to each person who has been harmed
4 People have the power to overcome alcoholism if they truly want to stop drinking
61. A nurse in the ED is implementing a plan of care for an older adults client
who is experiencing delirium tremens. Which of the following actions should
the nurse take first?
A. Administer diazepam
B. Raise the side rails of the bed
C. Obtain a medical history
D. Start IV fluids