Question 39 - Safety and Infection Control Practice Test for the NCLEX-PN Exam

Use the case study information provided to answer this question.

For each of the following nursing interventions, select which ones would be indicated or not indicated for this client.

    A B
  Nursing Intervention Indicated Not Indicated
1. Monitor client’s vital signs every two hours
while he is going through alcohol withdrawals.		    
2. Request a sitter to be in the room while client
is going through withdrawals.		    
3. Apply restraints as needed during
periods of agitation.		    
4. Provide a calm safe environment free
from harmful objects.		    

Intro to Case

The LPN is taking care of a 43-year-old male client on the medical-surgical floor. He was recently admitted with alcohol withdrawal symptoms.

Nurse’s Notes

2200: Admission assessment completed by RN. Client states he has not had an alcoholic beverage in 10 hours and “doesn’t feel right.” He states he is trying to quit, but doesn’t know if he will be able to without medical treatment. He has been a heavy drinker since he was 14 years old. Client’s hands are visibly shaking and forehead is sweating.

0200: Client’s bed alarm is going off and nurse called into room because he believes he is covered in spiders. He is screaming and running all around the room. Client pulled his peripheral IV out and there is blood pouring from his forearm. Nurse reoriented client to place and informs client there are no spiders crawling on him at this time. Client is very agitated and will not stay in the bed. Client agreed to let nurse take his vital signs while standing up.

History and Physical

Body System Findings
Neurological Client is AAO x 4. Perrla. Hands shaking and client complaining
of a headache 6/10. Client
has a hx of seizures, anxiety, and depression.
Cardiovascular Hx of hypertension, hyperlipidemia, tachycardia
Respiratory Current 1 PPD smoker. Hx of COPD and OSA. On 2 L of oxygen at night. Client had COVID-19 one month ago.
Musculoskeletal Hx of multiple sclerosis (MS), diagnosed 5 years ago. Client states
he has some weakness at times and
occasional numbness and tingling in
extremities
   

Vital Signs

  2200 0200
BP \(162/86\) \(158/78\)
T \(98.7^\circ \text{F}\) \(99.2^\circ \text{F}\)
HR \(114\) \(130\)
RR \(18\) \(22\)
SpO\(_2\) \(95\%\) \(85\%\)
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