A nurse is talking with a 57-year-old client who has been a heavy drinker for many years. The client is being treated for alcoholism, and this is her second week as an inpatient on the psychiatric unit.
It is 5:00 AM, and the client has been having difficulty sleeping. The client is an orthopedic nurse, and although she is clothed in a hospital-issued gown and robe, she is wearing a stethoscope around her neck that the nurse recognizes as belonging to one of the staff nurses. When the nurse asks her why she is wearing the stethoscope and where she got it, the client gives her a long and involved reply that basically describes how her nursing supervisor came to visit and gave it to her to wear so she'd remember to get well. The nurse suspects that the client may be experiencing which of the following?
A) Wernicke's syndrome
B) Delirium tremens
C) Korsakoff's psychosis
D) Malignant hyperthermia
Question 2
The nurse is completing the admission of a client who is seeking treatment for alcoholism. He tells the nurse that the last time he had any alcohol to drink was at 10:00 AM before he left for the hospital. The nurse closely monitors the client.
Which of the following would lead the nurse to suspect that the client is experiencing stage 1 of alcohol withdrawal syndrome? Select all that apply.
A) Slight diaphoresis
B) Hand tremors
C) Intermittent confusion
D) Heart rate of 135 beats/min
E) Normal blood pressure
The patient and his family meet with the nurse to discuss progress on the patient care plan.
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
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