The nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following diagnoses receives priority for a client in alcohol withdrawal?
1. Risk for Injury
2. Ineffective Coping
3. Disturbed Sensory Perception
4. Disturbed Thought Processes
1
Rationale: A client in alcohol withdrawal is at Risk for Injury from delirium tremens. Death from delirium tremens can occur from volume depletion, electrolyte imbalance, or cardiac arrhythmia. Disturbed Thought Processes and Disturbed Sensory Perceptions are diagnoses used for delusions, hallucinations, and illusions that may occur during delirium tremens. Ineffective Coping is a diagnosis used for substance abuse.
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The nurse explains that a type 2 hypersensitivity reaction results in
a. antibody formation. b. cell destruction. c. mast cell production. d. T-cell stimulation.
A client has been treated in the emergency department after a tornado and is awaiting discharge instructions. This client is close to losing control, although other family members are attempting to calm him down
Which response by the nurse is most helpful? a. Call security and have them standing by in case they are needed. b. Instruct the person to leave the area until he can calm down. c. Offer the client the choice of waiting in the treatment room or the waiting room. d. Ask the family to help move the client out of the treatment area.
While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action?
a. Let the neonate rest before breastfeeding again. b. Resume gavage feedings until the neonate is asymptomatic. c. Recognize that this may indicate an underlying illness. d. Use a high-flow, pliable nipple because it requires less energy to use.