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NurseDive Free Nursing Practice Question
A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?
A. Tachycardia
B. Cramping
C. Seizures
The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.
D. Elevated temperature
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.
Similar Questions
A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath.Which of the following actions should the nurse take first?
A. Call the supervisor to ask for another nurse.
B. Remove the nurse from the client care area.
The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.
C. Assign clients to the remaining staff.
D. Document objective findings about the situation.
Full Explanation
Explanation: The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.
A nurse is reinforcing dietary teaching with a client whose prepregnancy BMI was 30.5. The nurse should include that which of the following is an acceptable weight gain for this client?
A. 32 lb
B. 8 lb
C. 16 lb
According to the Institute of Medicine, women who are obese before pregnancy (BMI of 30 or higher) should gain 11 to 20 pounds during pregnancy. Therefore, 16 lb is an acceptable weight gain for this client.
D. 24 lb
Full Explanation
Explanation: According to the Institute of Medicine, women who are obese before pregnancy (BMI of 30 or higher) should gain 11 to 20 pounds during pregnancy. Therefore, 16 lb is an acceptable weight gain for this client.
A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?
A. "I wouldn't worry about this right now. Let's focus on your chemotherapy."
B. I will get you information about some head-covering options."
I will get you information about some head-covering options." Explanation: This response shows empathy and respect for the client's concerns and provides information and support for coping with hair loss. The other responses are dismissive, evasive, or intrusive.
C. "Let's discuss this when we have more time."
D. "I can't imagine how difficult it would be to lose my hair."
Full Explanation
Answer: B. I will get you information about some head-covering options." Explanation: This response shows empathy and respect for the client's concerns and provides information and support for coping with hair loss. The other responses are dismissive, evasive, or intrusive.