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Difficulty: HardMental Health Concepts

An adult client with a history of alcohol use disorder and major depressive disorder is admitted to a medical unit for the treatment of severe pneumonia. On the third day of hospitalization, the client, who previously exhibited profound sadness and psychomotor retardation, suddenly appears peaceful and states, "I finally figured out how to solve all my problems. I will not be a burden to my family anymore." The nurse also notes that the client is diaphoretic and has visible bilateral hand tremors. Which of the following nursing actions are appropriate to include in the immediate plan of care? Select all that apply.

  1. Ask the client directly if they are having thoughts of self-harm or suicide.Answer
  2. Initiate continuous, one-to-one observation of the client.Answer
  3. Implement environmental seizure precautions.Answer
  4. D
    Respond to the client by stating, "I am so glad you are finally feeling at peace today."
  5. E
    Delegate the administration of the standardized withdrawal assessment scale to the unlicensed assistive personnel (UAP).
  6. F
    Document the tremors and diaphoresis as a normal physiological response to the resolving pulmonary infection.

Answer

The correct actions include asking the client directly about suicidal thoughts, initiating continuous one-to-one observation, and implementing environmental seizure precautions.
The client is simultaneously experiencing two life-threatening emergencies. First, the sudden shift from deep depression to a peaceful state, combined with the statement about not being a burden, is a classic warning sign of impending suicide. This necessitates asking the client directly about self-harm and placing them on continuous 1:1 observation. Second, diaphoresis and hand tremors on the third day of hospitalization in a client with alcohol use disorder indicate severe alcohol withdrawal. Because this can rapidly progress to delirium tremens and seizures, implementing seizure precautions is a critical safety priority.

Step-by-Step Solution

1
Analyze the client's psychiatric risk factors and statements.
The client has major depressive disorder and shows a sudden, unexplained shift from profound sadness to a peaceful state, accompanied by a statement about no longer being a burden.
Sudden mood improvement often indicates the client has finalized a suicide plan and feels relief. This requires immediate direct assessment of suicidal intent and implementation of 1:1 safety observation.
2
Analyze the client's medical history and physical assessment findings.
The client has a history of alcohol use disorder, is on day 3 of hospitalization (72 hours since last drink), and is exhibiting diaphoresis and bilateral hand tremors.
These factors strongly indicate progressing acute alcohol withdrawal, which peaks around 48-72 hours. The client is at imminent risk for delirium tremens and withdrawal seizures, requiring immediate seizure precautions.
3
Evaluate the nursing actions for safety and scope of practice.
Therapeutic communication must address the suicide risk rather than validating the calm mood. Assessment of withdrawal severity must remain with the RN.
Delegating complex assessments to UAPs or providing false reassurance compromises patient safety and violates established standards of psychiatric and medical-surgical nursing care.

Key Concept

Prioritizing physiological and psychological safety in clients with dual diagnoses (Alcohol Withdrawal Syndrome and Suicidal Ideation).
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