Exam (elaborations) Andrew Davis Post

Your Response:Motor 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? 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: Keep SpO2 probe at bedside, Assess and record heart rate every 4 hours, Implement 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.) 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? Your Response:Observing seizure precautions Your Response:Never experiencing alcohol withdrawal signs and symptoms before Your Response:Respiratory rate of 11 breaths/minute Rationale:Because alcohol withdrawal can be life-threatening, detoxification needs to be medically supervised. Although the other options may be true statements, none effectively addresses the seriousness of the withdrawal process and the possible risk to life that it presents. Remediation: Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, p.360 5Which factor is most likely to decrease the severity of Mr. Davis's alcohol withdrawal signs and symptoms? Rationale:Symptoms of alcohol withdrawal are typically more severe in older individuals and in those who have had previous alcohol withdrawal experiences. Although his age is a risk factor, Mr. Davis has had no previous withdrawal experiences, and this is a protective factor. Symptom severity is related more to quantity and type of alcohol consumed regularly than the length of the patient's drinking history. Mr. Davis's religious faith would be considered a protective factor in his recovery but has no relevance to the severity of his withdrawal. 6Mr. Davis has been prescribed an oral benzodiazepine to assist in managing his withdrawal symptoms should his CIWA-Ar score rise to 8 or above. After a dose has been administered, what assessment result, directly related to the medication, would be a concern for the nurse? Rationale:CNS depression is a side effect of benzodiazepines. A respiratory rate of 11 breaths/minute could indicate respiratory depression and thus should be a concern for the Your Response:"Alcohol withdrawal can be life-threatening and thus requires care provided by trained staff." Your Response: Near continuous pacing, Experiencing tactile disturbances, Admitting to visual hallucinations, Disoriented by more than 2 calendar days Your Response:The signs and symptoms are likely to increase in type and severity. nurse. The blood pressure is baseline for this patient and a headache is a classic symptom of alcohol withdrawal. Tinnitus is not generally associated with an adverse reaction to a benzodiazepine. Remediation: Lippincott Advisor, Drugs: Diazepam 7 What characteristic behavior demonstrated by Mr. Davis is associated with Stage III withdrawal symptoms? (Select all that apply.) Rationale:Clinical manifestations of Stage III or severe withdrawal symptoms would include continuous pacing associated with agitation, both tactile and visual disturbances/hallucinations, and disorientation for date by 2 or more days. Oral temperature would be elevated. Remediation: Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, pp. 360-361 8Mr. Davis reported having consumed his last drink around 4 pm, and he was admitted to the facility's detoxification unit shortly thereafter. What clinical manifestations of alcohol withdrawal should the nurse expect him to demonstrate by 10 pm that night? Rationale:Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. The signs and symptoms of alcohol withdrawal gradually intensify and usually peak on the second day and are over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Since Mr. Davis has been without alcohol for an estimated 6 hours, his clinical manifestations are very likely to increase in both type and severity. Remediation: Your Response: Minimize all sources of noise in his room., Dim the lighting in his room., Suction equipment is kept at the bedside., Institute falls precautions. Your Response:Ensure that his needs are met in a nonjudgmental manner. Videbeck, S. Psychiatric-Mental Health Nursing, 8th Edition, p. 360 9 Which nursing interventions would best address Mr. Davis's safety issues if his CIWA-Ar score were to rise to 8 or above? (Select all that apply.) Rationale:Assuring patient safety is the primary nursing responsibility. With the potential for seizures, both lighting and noise should be minimized in Mr. Davis' environment. His mental and physical state places him at increased risk for falls and aspiration, making those interventions necessary. His nutritional issues should be assessed and addressed when he is considered stable and through the withdrawal. Remediation: Lippincott Procedures, Alcohol withdrawal management 10How can the nurse caring for Mr. Davis best provide the appropriate emotional care during his alcohol withdrawal? Rationale:It is a nursing obligation to provide nonjudgmental, supportive, empathetic, and comprehensive emotional care to all patients regardless of one's personal feelings. While family support is important, the increased stimulation resulting from their presence at the bedside is not generally encouraged. While the remaining options present accurate information about the nature and length of the withdrawal, neither statement addresses emotional support.