NCLEX-RN
Mental Health RN NCLEX Questions Questions
Extract:
The nurse in the intensive care unit (ICU) is caring for a 53-year-old male client.
Item 3 of 6
Nurses' Notes
Laboratory Results
1222: Client brought via ambulance to ED because of altered mental status and agitation. The client's wife reports that the client stopped drinking alcohol 'cold turkey' two days ago. This morning, the client was agitated, sweating, and altered. The client's wife reports that the client drinks 6-8 alcoholic beverages daily. On assessment, the client is alert and agitated. He recognizes that he is in the hospital but cannot recall the reasoning. Nystagmus was present. Skin is flushed and diaphoretic. Lung sounds are clear bilaterally. S1/S2 heart tones with mid-
systolic clicks. Peripheral pulses 1+. Abdomen is taut with normoactive bowel sounds. Vital signs: T 99.4°F (37.4°C), P 108. RR 18, BP 158/96, pulse oximetry 95% on room air. Medical history of hypertension, hyperlipidemia, and mitral valve prolapse. Home medications hydrochlorothiazide and multivitamin. EMS placed a 20-gauge peripheral vascular access device in the left antecubital space.
1239: Physician provided verbal order to obtain laboratory work (complete blood count, magnesium level, and basic metabolic panel). 1311: Laboratory results received and reviewed. The nurse updates the nurses' notes.
Question 1 of 5
The nurse should immediately address the client's
Correct Answer: B
Rationale: Altered mental status is a critical symptom of alcohol withdrawal, indicating potential progression to severe complications like delirium tremens, requiring immediate attention.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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