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Difficulty: HardSubstance Use and Other Disorders

A practical nurse (PN) is monitoring a client in a short-term rehabilitation unit who is recovering from a fractured pelvis. The client's relative recently disclosed that the client drinks a large amount of whiskey every evening, a fact the client explicitly denied during the initial assessment. It is now the third day of the client's stay. The PN enters the room and finds the client completely drenched in sweat, trembling violently, and frantically trying to swat away "bats" from the ceiling. Which action should the PN take first?

  1. Stay at the bedside, clear the immediate area of any hazards, and use the emergency call system to summon the registered nurse.Answer
  2. B
    Note the acute confusion in the electronic chart as expected cognitive decline worsened by the stress of the facility transfer.
  3. C
    Firmly inform the client that there are no bats in the room and the visions are merely a side effect of the pain medication.
  4. D
    Draw up and deliver the prescribed PRN dose of intravenous (IV) push diazepam to immediately depress the central nervous system.

Answer

The priority action is to remain with the client, secure the physical environment from hazards, and immediately call for the registered nurse.
The client's presentation of severe tremors, profound diaphoresis, and vivid visual hallucinations at 72 hours post-admission, combined with a history of heavy alcohol use, strongly indicates alcohol withdrawal delirium (delirium tremens). This is a life-threatening medical emergency. The absolute priority for the PN is to ensure immediate physical safety by staying with the client and clearing the area of hazards, while simultaneously activating the call light to urgently involve the registered nurse and provider for emergency pharmacological management.

Step-by-Step Solution

1
Analyze the client's clinical presentation and timeline.
The client is exhibiting severe diaphoresis, severe tremors, and visual hallucinations approximately 72 hours post-admission.
Recognizing these specific cues alongside the hidden history of heavy daily alcohol use points directly to alcohol withdrawal delirium (delirium tremens), rather than a standard post-operative complication.
2
Determine the priority nursing intervention based on the severity of the condition.
The immediate priority is client safety and rapid medical escalation.
Alcohol withdrawal delirium is a medical emergency that can rapidly progress to severe seizures, cardiovascular collapse, and death, requiring immediate pharmacological management.
3
Evaluate the available options against safety principles and the PN scope of practice.
Remaining with the client and calling for the RN is the most appropriate action.
The PN must secure the environment and ensure the client is never left alone during acute delirium, while rapidly securing RN assistance since IV push medications are required but out of the PN scope.

Key Concept

Alcohol Withdrawal Delirium (Delirium Tremens) and PN Scope of Practice
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Topics

Substance Use and Other Disorders

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