Free NCLEX-RN Exam Braindumps (page: 37)

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Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:

  1. Maintaining seizure precautions
  2. Restricting fluid intake
  3. Increasing sensory stimuli
  4. Applying ankle and wrist restraints

Answer(s): A

Explanation:

(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.



Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:

  1. Maintaining seizure precautions
  2. Restricting fluid intake
  3. Increasing sensory stimuli
  4. Applying ankle and wrist restraints

Answer(s): A

Explanation:

(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.



Hematotympanum and otorrhea are associated with which of the following head injuries?

  1. Basilar skull fracture
  2. Subdural hematoma
  3. Epidural hematoma
  4. Frontal lobe fracture

Answer(s): A

Explanation:

(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.



Hematotympanum and otorrhea are associated with which of the following head injuries?

  1. Basilar skull fracture
  2. Subdural hematoma
  3. Epidural hematoma
  4. Frontal lobe fracture

Answer(s): A

Explanation:

(A) Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms. (B, C, D) These do not typically cause dural lacerations and CSF leakage.






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