Andrew Davis Post-Quiz
1A client with a blood alcohol level of 0.20 mg% is at a high risk for injury related to the
impairment of which function?
Your Response:Motor
Rationale:Alcohol is a central nervous system depressant that is absorbed rapidly into the
bloodstream. With a blood alcohol level of 0.20 mg%, the client is at risk for injuries related to
severely impaired motor function. Consciousness and orientation are affected when levels rise
to 0.30 mg%. Respiratory failure is possible with a blood alcohol level of 0.50 mg%.
Remediation:
Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, p. 360
2A patient with a history of chronic alcohol abuse has begun to demonstrate signs and
symptoms of delirium tremens (DTs). The nurse demonstrates an understanding of the
seriousness of the patient's risk for injury when implementing which intervention?
, Your Response:Observing seizure precautions
Rationale:Severe or untreated withdrawal may progress to DTs. Grand mal (tonic-clonic)
seizures are a possible manifestation of DTs. Seizure precautions would be most appropriate to
help in the management of this possible event. Although disorientation and hallucinations are
possible, they do not pose the same degree of risk for injury as does a seizure. The patient
doesn't benefit from being restricted to the room, but staff should closely monitor the patient.
Remediation:
Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, p. 360
Lippincott Procedures, Alcohol withdrawal management
3
Which nursing interventions are directly associated with the primary goals of the
management of a patient, like Mr. Davis, who is currently experiencing alcohol
withdrawal? (Select all that apply.)
Your Response: Keep SpO2 probe at bedside, Assess and record heart rate every 4 hours,
Implement seizure precautions
Rationale:The primary goals of managing a patient with alcohol withdrawal are to maintain
circulation, airway, breathing, and patient safety. Supportive measures should be provided as
indicated by the patient's condition. Depending on the patient's condition after withdrawal
symptoms resolve, alcohol dependence treatment such as AA groups and abuse triggers should
be considered.
Remediation:
Lippincott Procedures, Alcohol withdrawal management
4How should the nurse respond when asked why alcohol withdrawal and detoxification
should be managed in a hospital setting?
1A client with a blood alcohol level of 0.20 mg% is at a high risk for injury related to the
impairment of which function?
Your Response:Motor
Rationale:Alcohol is a central nervous system depressant that is absorbed rapidly into the
bloodstream. With a blood alcohol level of 0.20 mg%, the client is at risk for injuries related to
severely impaired motor function. Consciousness and orientation are affected when levels rise
to 0.30 mg%. Respiratory failure is possible with a blood alcohol level of 0.50 mg%.
Remediation:
Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, p. 360
2A patient with a history of chronic alcohol abuse has begun to demonstrate signs and
symptoms of delirium tremens (DTs). The nurse demonstrates an understanding of the
seriousness of the patient's risk for injury when implementing which intervention?
, Your Response:Observing seizure precautions
Rationale:Severe or untreated withdrawal may progress to DTs. Grand mal (tonic-clonic)
seizures are a possible manifestation of DTs. Seizure precautions would be most appropriate to
help in the management of this possible event. Although disorientation and hallucinations are
possible, they do not pose the same degree of risk for injury as does a seizure. The patient
doesn't benefit from being restricted to the room, but staff should closely monitor the patient.
Remediation:
Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, p. 360
Lippincott Procedures, Alcohol withdrawal management
3
Which nursing interventions are directly associated with the primary goals of the
management of a patient, like Mr. Davis, who is currently experiencing alcohol
withdrawal? (Select all that apply.)
Your Response: Keep SpO2 probe at bedside, Assess and record heart rate every 4 hours,
Implement seizure precautions
Rationale:The primary goals of managing a patient with alcohol withdrawal are to maintain
circulation, airway, breathing, and patient safety. Supportive measures should be provided as
indicated by the patient's condition. Depending on the patient's condition after withdrawal
symptoms resolve, alcohol dependence treatment such as AA groups and abuse triggers should
be considered.
Remediation:
Lippincott Procedures, Alcohol withdrawal management
4How should the nurse respond when asked why alcohol withdrawal and detoxification
should be managed in a hospital setting?
