A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention?
1. To assess for emotional strength
2. To assess for Wernicke-Korsakoff syndrome
3. To assess for tachycardia
4. To assess for fine tremors
4
Rationale: The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, and coarse tremors.
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A visiting nurse is making a visit to a home where the wife is caring for her husband who has Alzheimer's disease and is prone to wander. Which of the following observations by the nurse is cause for additional instruction for the wife?
A) motion detector alarms are in place on the door of the room where the client sleeps B) exit doors in the home have slide bolt locks at the bottoms C) phone numbers of Safe Return and the local police are posted on the outside of the refrigerator door in the kitchen D) car keys are on a key rack by the front door
The client has a peritonsillar abscess. What is the priority instruction the nurse should provide to this client?
A. "If you notice an enlarged lymph node on the same side of your neck as the ab-scess, call the doctor." B. "Stay home from work or school until your temperature has been normal for 24 hours." C. "You may gargle with warm water that has a teaspoon of salt in it as often as you like." D. "Take the antibiotic for the entire time it is prescribed, not just until you feel bet-ter."
Which of these musculoskeletal changes is a result of normal aging?
a. Joints develop degenerative changes. b. Coordination and endurance are unaffected. c. Muscle mass and elasticity remain unchanged. d. Osteoporosis is to be expected.
Which of the following signs and symptoms would the nurse expect to see for a patient going into anaphylactic shock? (Select all that apply.)
a. Urticaria b. Polyuria c. Laryngeal edema d. Bronchospasm