Page 2320 - Saunders Comprehensive Review For NCLEX-RN

include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations,
changes in level of consciousness, agitation, fever, and delusions.
Test-Taking Strategy: Focus on the subject, findings associated with withdrawal
delirium. Review each option carefully to ensure that all symptoms in the option are
correct. Eliminate options 1 and 3 first, knowing that hypertension rather than
hypotension occurs. From the remaining options, recalling that the client who is
stuporous is not likely to exhibit withdrawal delirium will direct you to the correct
option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Mental Health
Health Problem: Mental Health: Addictions
Priority Concepts: Addiction; Clinical Judgment
Reference: Varcarolis (2017), p. 303.

825. Answer: 2

Rationale: The most helpful response is one that encourages the client to solve
problems. Giving advice implies that the nurse knows what is best and can foster
dependency. The nurse should not agree with the client, and the nurse should not
request that the client provide explanations.
Test-Taking Strategy: Note the strategic word, most. Use therapeutic
communication techniques. Eliminate option 1 because of the word why, which
should be avoided in communication. Eliminate option 3, because this option places
the client’s feelings on hold. Eliminate option 4, because the nurse is agreeing with
the client. The correct option is the only one that addresses the client’s feelings.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Health Problem: Mental Health: Addictions
Priority Concepts: Caregiving; Communication
Reference: Varcarolis (2017), pp. 97-98, 302.

826. Answer: 2

Rationale: Disturbed body image is a concern with clients with anorexia nervosa.
Although the client may struggle with ambivalence and show regressed behavior,
the client’s coping pattern relates to the basic issue of disturbed body image. The
nurse should address this need in the support group.
Test-Taking Strategy: Note the subject, signs of disturbed body image. Note the
relationship between the information in the question and the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Mental Health

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