NCLEX-RN
NCLEX RN Mental Health Questions Questions
Extract:
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 53-year-old male client.
Item 2 of 6
Nurses' Notes
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.
Question 1 of 5
Which of the following issues is the client at risk of developing? Select all that apply.
Correct Answer: A,B,C,D,E
Rationale: Abrupt alcohol cessation increases risks for seizures, delirium tremens, Wernicke's encephalopathy, electrolyte imbalances, and cardiac dysrhythmias due to withdrawal effects.
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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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