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4.A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The patient shouts, “Bugs are crawling on my bed. I’ve got to get out of here.” Select the most accurate assessment of this situation. The patienta.is attempting to obtain attention by manipulating staff.b.may have sustained a head injury before admission.c.has symptoms of alcohol withdrawal delirium.d.is having an acute psychosis.ANS: CSymptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol withdrawal delirium. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.PTS:1DIF:Cognitive Level: Understand (Comprehension)REF:Pages 22-31, 32, 72 (Table 22-6)TOP:Nursing Process: AssessmentMSC:Client Needs: Physiological Integrity5.
A patient admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?
The patient’s clouded sensorium, sensory perceptual distortions, and poor judgment predispose a risk for injury. Safety is the nurse’s priority. The other diagnoses may apply but are not the priorities of care.PTS:1DIF:Cognitive Level: Analyze (Analysis)REF:Pages 22-31, 32 | Pages 22-39, 69 (Table 22-5)TOP:Nursing Process: Diagnosis/AnalysisMSC:Client Needs: Safe, Effective Care Environment6.A hospitalized patient diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n)Sedation allows for safe withdrawal from alcohol. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties.PTS:1DIF:Cognitive Level: Apply (Application)REF:Pages 22-31, 32, 72 (Table 22-6)TOP:Nursing Process: PlanningMSC:Client Needs: Physiological Integrity