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Difficulty: Very hardChemical and Other Dependencies / Substance Use Disorders

A 35-year-old client is admitted to the trauma unit following a motor vehicle collision. The electronic health record notes a history of daily, heavy consumption of both opioids and alcohol, though the client's family reports the client has not used any substances for the past 36 hours. The client suddenly becomes intensely restless, exhibits coarse bilateral hand tremors, profuse diaphoresis, and attempts to pull out their peripheral intravenous (IV) line, shouting, "You are pumping poison into my veins!" Current vital signs are a heart rate of 128 bpm, blood pressure of 172/98 mmHg, and respiratory rate of 22 breaths/min. The registered nurse (RN) is coordinating care with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which action should the RN take FIRST?

  1. Initiate seizure precautions, remain at the bedside in a low-stimulation environment, and direct the LPN to urgently notify the healthcare provider of the client's status.Answer
  2. B
    Instruct the UAP to immediately apply soft wrist restraints to secure the IV line, then document the client's sudden behavioral changes.
  3. C
    Ask the client, "Why do you believe the nurses are poisoning you?" to help them process their paranoid delusions before intervening.
  4. D
    Prepare to administer PRN methadone for opioid withdrawal and assign the UAP to monitor the client's vital signs every 15 minutes.

Answer

The RN should initiate seizure precautions, remain at the bedside in a low-stimulation environment, and direct the LPN to urgently notify the healthcare provider of the client's status.
The correct action directly addresses the highest priority need: patient safety during a life-threatening alcohol withdrawal crisis. By initiating seizure precautions and staying with the client, the RN prevents injury. Delegating the provider notification to the LPN is an excellent use of team resources, ensuring the client is not left alone while rapidly securing the necessary medical orders (such as benzodiazepines).

Step-by-Step Solution

1
Analyze the client's history, timeline of substance cessation, and current clinical manifestations.
Identifies that 36 hours post-cessation with coarse tremors, extreme autonomic hyperactivity (HR 128, BP 172/98), and hallucinations strongly indicate severe alcohol withdrawal, not opioid withdrawal.
Accurate differentiation between withdrawal syndromes is required to anticipate the correct medical and nursing interventions.
2
Determine the physiological risk and prioritize the nursing framework.
Recognizes the onset of impending Delirium Tremens (DTs), which carries a high risk of fatal seizures and cardiovascular collapse, placing physiological safety as the absolute priority.
Safety protocols must be established immediately to prevent injury before or while waiting for pharmacological treatment.
3
Select the safest, most effective initial nursing action incorporating proper delegation.
Chooses to initiate seizure precautions and maintain a safe RN presence, while delegating the critical task of provider notification to the LPN.
The RN must not leave an unstable, hallucinating client unattended. The LPN is operating within their scope of practice by communicating urgent assessment findings to the provider on the RN's behalf.

Key Concept

Nursing management of severe alcohol withdrawal requires immediate recognition of autonomic hyperactivity and delirium, prioritization of seizure precautions and continuous observation, and rapid communication with the provider for pharmacological intervention.
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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