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Question

Difficulty: HardChemical and Other Dependencies / Substance Use Disorders

A nurse is caring for a client hospitalized with acute pancreatitis related to heavy, daily alcohol consumption. The client reports their last alcoholic beverage was approximately 14 hours ago. During morning rounds, the client is pacing the room continuously, appears highly anxious, and repeatedly demands to leave the facility against medical advice. Current vital signs reveal a heart rate of 112 bpm, blood pressure of 148/92 mm Hg, and mild diaphoresis. Which action is the priority for the nurse to implement?

  1. Administer the prescribed as-needed dose of a benzodiazepine.Answer
  2. B
    Initiate an open-ended dialogue to explore why the client wishes to leave.
  3. C
    Direct the unlicensed assistive personnel to stay in the room and closely monitor behavior.
  4. D
    Request a prescription for bilateral soft wrist restraints to prevent elopement.

Answer

The priority action is to administer the prescribed as-needed dose of a benzodiazepine.
The client is exhibiting classic early manifestations of acute alcohol withdrawal, including psychomotor agitation (pacing), anxiety, tachycardia, hypertension, and diaphoresis. These symptoms typically begin 6 to 24 hours after the cessation of heavy alcohol use. The priority nursing action is to administer a cross-tolerant central nervous system depressant, such as a benzodiazepine, to manage the autonomic hyperactivity, prevent the progression to withdrawal seizures or delirium tremens, and safely reduce the client's severe agitation.

Step-by-Step Solution

1
Analyze the client's timeline and clinical history.
The client has a history of heavy, daily alcohol use and the last drink was 14 hours ago.
Establishing the timeline is critical for predicting the onset and stage of alcohol withdrawal.
2
Evaluate the current physical and behavioral manifestations.
The client exhibits pacing, anxiety, tachycardia (112 bpm), hypertension (148/92 mm Hg), and diaphoresis.
These findings must be correlated with potential complications based on the client's substance use history.
3
Synthesize the data to identify the primary clinical problem.
The findings represent early but escalating signs of acute alcohol withdrawal.
Recognizing the physiological etiology of the agitation prevents misclassifying it as purely a behavioral or psychosocial issue (e.g., just wanting to leave AMA).
4
Determine the priority nursing intervention based on physiological stability.
Pharmacological management with a cross-tolerant central nervous system depressant is required immediately.
Untreated alcohol withdrawal can rapidly progress to life-threatening seizures or delirium tremens, making physiological stabilization the highest priority.

Key Concept

Recognition and pharmacological management of acute alcohol withdrawal
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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