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Question

Difficulty: MediumSubstance Use and Other Disorders

A 68-year-old client is receiving care in a medical-surgical unit for community-acquired pneumonia. Two days after admission, the practical nurse (PN) observes that the client is highly restless, sweating profusely, and has noticeable hand tremors. The client suddenly points at the wall and says, "Look at the spiders crawling everywhere!" Which action should the PN take first?

  1. Remain with the client to maintain safety and immediately notify the registered nurse (RN).Answer
  2. B
    Logically explain to the client that the wall is empty and there are no spiders.
  3. C
    Apply soft wrist restraints immediately to prevent the client from dislodging any medical lines.
  4. D
    Reassure the client's family that sudden confusion is a normal expectation for older adults with an infection.

Answer

The priority action is to remain with the client to maintain safety and immediately notify the registered nurse (RN).
The client is displaying symptoms consistent with acute alcohol withdrawal delirium, an emergency condition that typically peaks 48 to 72 hours after the last drink. The priority is safety. By remaining with the client, the practical nurse prevents potential injury from agitation or a seizure. Simultaneously notifying the RN is crucial because the client will require an advanced assessment and likely urgent pharmacological interventions (such as benzodiazepines) that fall outside the independent scope of the PN.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting restlessness, diaphoresis, hand tremors, and visual hallucinations approximately 48 hours after admission.
These are classic early warning signs of complicated alcohol withdrawal (delirium tremens), a life-threatening medical emergency.
2
Determine the most immediate risk to the client.
The client is at high risk for self-injury, escalating agitation, and seizures.
Visual hallucinations and autonomic hyperactivity impair judgment and require immediate protective measures.
3
Select the appropriate nursing intervention within the PN scope of practice.
The PN chooses to stay with the client to ensure physical safety and simultaneously calls for the RN.
The PN provides direct observation to prevent injury while escalating the situation to the RN for advanced assessment and medication administration.

Key Concept

Prioritizing Client Safety and RN Collaboration in Alcohol Withdrawal
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Topics

Substance Use and Other Disorders

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