Which finding suggests to the nurse that a patient is experiencing early physiologic clinical manifestations of alcohol withdrawal? The patient:
1. Is yelling at the nurse and demanding to go home
2. Has a BP of 160/90, HR of 110, and T of 100
3. Is a well-known repeat offender and is demanding a drink
4. Cannot sit up straight or respond appropriately to questions
2
Rationale 1: Yelling and acting belligerent is a behavioral and neuropsychiatric manifestation of alcohol withdrawal syndrome.
Rationale 2: Vital signs including temperature and pulse oximetry are evaluated. Early indications of alcohol withdrawal tend to be milder increases in heart rate, temperature, and blood pressure with more severe symptoms such as hallucinations developing as the patient progresses through the continuum.
Rationale 3: Being a repeat offender and demanding a drink is a behavioral manifestation of alcohol withdrawal syndrome.
Rationale 4: Lethargy and decreased responsiveness is a later manifestation of alcohol withdrawal syndrome.
You might also like to view...
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.
The nurse is administering a controlled substance that is ordered in a smaller dose than what is available. What should the nurse do with the remaining amount of medication?
a. Save the remaining medication until the patient is scheduled to take the medication again. b. Flush the remaining medication in the toilet in the patient's bathroom. c. Ask another nurse to witness the waste, sign the inventory report, and document the situation. d. Administer the dose that is available and not the smaller dose ordered.
The nurse is caring for an older patient who only speaks Spanish. To meet the national standards for culturally and linguistically appropriate services in healthcare, what will the nurse do? Standard Text: Select all that apply
1. Offer language assistance services to the patient. 2. Post signs in the patient's room written in Spanish. 3. Encourage the patient's family members to serve as interpreters. 4. Explain the cost to employ an interpreter to help the patient with language needs. 5. Provide a written notice in the patient's language informing of the right to receive language assistance services.
A nurse is to obtain a daily urine pH as ordered. The client would most likely be receiving which of the following anti-infectives for a UTI because they work better in acidic urine? Select all that apply
A) Methenamine (Hiprex) B) Amoxicillin (Amoxil) C) Fosfomycin (Monurol) D) Nitrofurantoin (Macrodantin) E) Nalidixic (NegGram)