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Difficulty: HardSubstance Use and Other Disorders

An older adult client is hospitalized for a lower respiratory tract infection. The medical history indicates chronic, daily alcohol consumption. Thirty-six hours after admission, the client suddenly exhibits profound disorientation, severe agitation, and claims to see insects crawling on the ceiling. Which action is most appropriate for the practical nurse to take?

  1. Remain in the room to protect the client from injury while directing another staff member to alert the registered nurse.Answer
  2. B
    Prepare and administer an intravenous push benzodiazepine per the facility's standing alcohol withdrawal protocol.
  3. C
    Document the behavioral changes in the electronic health record as an expected progression of senile dementia.
  4. D
    Attempt to logically convince the client that the insects are not real and are merely a symptom of the infection.

Answer

Remain in the room to protect the client from injury while directing another staff member to alert the registered nurse.
The client is exhibiting classic signs of alcohol withdrawal delirium, a medical emergency requiring immediate pharmacological intervention and rigorous safety measures. The practical nurse's priority is to ensure the client's physical safety by remaining present, while simultaneously delegating the task of notifying the registered nurse (RN). The RN is required to perform a comprehensive assessment and administer the necessary intravenous medications.

Step-by-Step Solution

1
Analyze the client's clinical presentation and timeline.
The sudden onset of severe agitation, disorientation, and visual hallucinations 36 hours after admission in a client with chronic alcohol use strongly indicates alcohol withdrawal delirium (delirium tremens).
Recognizing life-threatening withdrawal complications is the crucial first step in prioritizing care.
2
Prioritize interventions based on the nursing process and safety principles.
The client is actively hallucinating and severely agitated, placing them at an immediate high risk for falls, self-injury, or elopement.
Physical safety takes absolute precedence in acute psychiatric or substance withdrawal emergencies.
3
Determine the appropriate action within the practical nurse scope of practice.
The practical nurse must maintain a safe environment by staying with the client while delegating the notification of the registered nurse to another staff member.
Scope of practice dictates that registered nurses must perform the comprehensive assessment and administer the intravenous medications required for an unstable client experiencing acute withdrawal.

Key Concept

Alcohol Withdrawal Delirium and Practical Nurse Scope of Practice
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Topics

Substance Use and Other Disorders

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