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Difficulty: EasyChemical and Other Dependencies / Substance Use Disorders

A nurse on a medical-surgical unit is assessing a client who has a history of heavy alcohol consumption. The client's last drink was approximately 48 hours ago. Which of the following clinical findings should the nurse recognize as manifestations of alcohol withdrawal? Select all that apply.

  1. Restlessness and agitationAnswer
  2. DiaphoresisAnswer
  3. Elevated blood pressureAnswer
  4. D
    Bradycardia
  5. E
    Increased appetite

Answer

The correct manifestations of alcohol withdrawal are restlessness and agitation, diaphoresis, and elevated blood pressure.
Because alcohol is a central nervous system depressant, abrupt cessation leads to a rebound effect known as autonomic hyperactivity. This overactivity results in expected withdrawal symptoms such as restlessness, agitation, diaphoresis (excessive sweating), and elevated blood pressure.

Step-by-Step Solution

1
Analyze the client's clinical history and timeline.
The client has a history of heavy alcohol use and stopped drinking 48 hours ago.
Establishing the timeline helps identify that the client is within the peak window for acute alcohol withdrawal syndrome.
2
Recall the physiological effects of alcohol withdrawal.
Alcohol withdrawal leads to a rebound effect characterized by autonomic hyperactivity and central nervous system excitability.
Understanding that withdrawal causes hyperactive responses provides the basis for anticipating specific symptoms.
3
Evaluate each option against the expected signs of autonomic hyperactivity.
Restlessness, diaphoresis, and elevated blood pressure align with this hyperactive profile. Bradycardia and increased appetite do not.
Systematically verifying each option ensures that only the true manifestations of withdrawal are selected.

Key Concept

Clinical manifestations of alcohol withdrawal syndrome
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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