A male client who is admitted with delirium tremens is dehydrated and experiencing auditory hallucinations. He has a bruised, swollen tongue and is confused. In developing a plan of care, which action should the nurse include to ensure the client is physiologically stable?

Correct Answer: A

Rationale: The correct answer is A: Monitor vital signs. This is crucial in managing a client with delirium tremens to ensure physiological stability. Monitoring vital signs such as blood pressure, heart rate, temperature, and respiratory rate can help identify any signs of deterioration or complications like dehydration, sepsis, or cardiovascular instability. By closely monitoring these parameters, the nurse can intervene promptly and prevent any further complications. Summary: - Option B is incorrect because administering antipsychotic medication is not the priority in managing delirium tremens. - Option C is incorrect as providing a quiet environment may help with managing hallucinations, but it does not address the physiological stability of the client. - Option D is incorrect as encouraging fluid intake is important for hydration but does not address the need for monitoring vital signs to ensure physiological stability.

Correct Answer: A

Rationale: The correct answer is A: Check the medication list. This is crucial as patients with schizophrenia often take antipsychotic medications that help manage their symptoms. Checking the medication list ensures the patient is receiving the appropriate treatment and dosage. Assessing for signs of infection (B) and monitoring vital signs (C) are important but not the priority in this case. Providing a quiet environment (D) is beneficial for patients with schizophrenia, but checking the medication list takes precedence to ensure proper treatment.

Correct Answer: D

Rationale: The correct answer is D: Nausea and vomiting. Lithium is known to cause gastrointestinal side effects, such as nausea and vomiting, which can potentially indicate toxicity. The RN should report this immediately to the healthcare provider as it could be a sign of lithium toxicity, which can be life-threatening. A: Short-term memory loss is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting. B: Five-pound weight gain is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting. C: Decreased affect is a common side effect of lithium, but it is not an urgent concern that requires immediate reporting.

Correct Answer: D

Rationale: The correct answer is D: Escort the client to his room. This intervention is best because it addresses the behavior causing disturbance without isolating the client or administering unnecessary sedatives. By escorting the client to his room, the nurse provides a supportive and non-punitive approach to managing the behavior. It allows the client to have a quiet space to calm down, reducing the annoyance to other clients. Isolating the client may worsen the behavior or create feelings of abandonment. Administering a sedative should be avoided unless absolutely necessary to ensure client safety. Avoiding recognizing the behavior does not address the issue or provide any support to the client.

Correct Answer: B

Rationale: Rationale: Option B is the correct choice because it adheres to a tyramine-restricted diet. Mashed potatoes, ground beef patty, corn, green beans, and apple pie are all low in tyramine. Tyramine is found in aged, fermented, and pickled foods, as well as in certain fruits and vegetables. The other options contain foods high in tyramine: hot dogs, banana bread, caffeinated coffee (Option A); avocado, ham, chocolate cake (Option C); and smoked sausage, cheddar cheese, and yeast rolls (Option D). Therefore, Option B is the best choice for a tyramine-restricted diet.