A client admitted with a long history of alcohol abuse is at risk to go through withdrawal and suffer delirium tremens (DTs). The nurse knows to assess the client for:
A)
lethargy and fine tremors.
B)
fever, diaphoresis, and hyperactivity.
C)
grand mal seizures.
D)
confusion, delusions, and hallucinations.
D
Explanation:
A)
When the substance is withdrawn, the central nervous system is stimulated; withdrawal associated with long-term alcohol use is also associated with cognitive symptoms.
Application
Assessment
Physiological Integrity: Physiological Adaptation
B)
When the substance is withdrawn, the central nervous system is stimulated; withdrawal associated with long-term alcohol use is also associated with cognitive symptoms.
Application
Assessment
Physiological Integrity: Physiological Adaptation
C)
When the substance is withdrawn, the central nervous system is stimulated; withdrawal associated with long-term alcohol use is also associated with cognitive symptoms.
Application
Assessment
Physiological Integrity: Physiological Adaptation
D)
When the substance is withdrawn, the central nervous system is stimulated; withdrawal associated with long-term alcohol use is also associated with cognitive symptoms.
Application
Assessment
Physiological Integrity: Physiological Adaptation
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An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as:
a. Depression. b. Weight gain. c. Hypertension. d. Social phobias.
When initiating a 24-hour urine collection, the nurse asks the patient to void. The nurse then _______ the specimen
ANS:
The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?
1) Continue to monitor the pump to see if the crack worsens. 2) Place the pump back on the utility room shelf. 3) A small crack poses no danger so continue using the pump. 4) Clearly label the pump and send it for repair.
Distinguishing delirium from dementia can be problematic since they may co-exist. The primary consideration in the differential is
A. Performance on the Mini Mental Status Exam B. The Confusion Assessment is negative C. Rapid change and fluctuating course of cognitive function D. The presence of behavioral symptoms with cognitive impairment