A patient admitted for injuries sustained while intoxicated has ...

[TFauchery]

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min.
 
  The patient shouts, Bugs are crawling on my bed. I've got to get out of here.. Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff.
  b. may have sustained a head injury before admission.
  c. has symptoms of alcohol-withdrawal delirium.
  d. is having an acute psychosis.

Question 2

A nurse documents: Patient mute despite repeated efforts to elicit speech. No eye contact. Short attention span; less than 1 minute. Which nursing diagnosis should be considered?
 
  a. Defensive coping
  b. Risk for violence
  c. Decisional conflict
  d. Impaired verbal communication

[Jossy]

Answer to Question 1

C
Symptoms of agitation, elevated pulse, and perceptual distortions indicate alcohol-withdrawal delirium, a medical emergency. The findings are inconsistent with manipulative attempts, head injury, or functional psychosis.

Answer to Question 2

D
The defining characteristics are more related to the nursing diagnosis of Impaired verbal communication than to the other nursing diagnoses.