A practical nurse (PN) is caring for a 71-year-old client in a rehabilitation center on the third day following a hip arthroplasty. The client suddenly exhibits severe restlessness, profuse diaphoresis, and visual hallucinations. A visiting relative remarks that the client consumes large amounts of liquor daily but has abstained since the surgery. What is the priority action for the PN?
- AExplain to the relative that sudden confusion is an expected adjustment reaction for older adults in a facility.
- BAsk the relative, 'Why did you keep the client's daily alcohol consumption a secret from the staff?'
- Implement seizure precautions and immediately report the client's change in status to the registered nurse (RN).Answer
- DPrepare and independently administer an intravenous (IV) push benzodiazepine to control the hallucinations.
Answer
The priority action is to implement seizure precautions and report the change in status to the registered nurse (RN).
The client's presentation of restlessness, diaphoresis, and hallucinations 48 to 72 hours after the last drink strongly suggests severe alcohol withdrawal (delirium tremens). This is a medical emergency with a high risk for seizures. The practical nurse must prioritize safety by initiating seizure precautions and immediately escalating the findings to the RN, who can perform a comprehensive assessment and obtain orders for necessary medical interventions.
Step-by-Step Solution
Key Concept
Alcohol Withdrawal Syndrome and Practical Nurse Scope of Practice