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Difficulty: MediumChemical and Other Dependencies / Substance Use Disorders

The registered nurse (RN) receives the morning shift report for a group of clients on a medical-surgical unit. Which client should the nurse assess first?

  1. A
    A client with an opioid use disorder admitted for cellulitis who is reporting severe muscle aches, diarrhea, excessive tearing, and yawning.
  2. A client admitted 48 hours ago for a gastric ulcer with a history of heavy daily alcohol consumption, who is now experiencing new-onset anxiety, diaphoresis, and a heart rate of 118 beats/min.Answer
  3. C
    A client admitted 4 hours ago for acute alcohol intoxication who is currently sleeping soundly with a heart rate of 72 beats/min and a respiratory rate of 14 breaths/min.
  4. D
    A client on day 4 of a structured alcohol detoxification protocol who is medically stable, whose family is actively asking the unlicensed assistive personnel (UAP) about long-term rehabilitation options.

Answer

The client admitted 48 hours ago who is experiencing new-onset anxiety, diaphoresis, and tachycardia requires the most immediate assessment.
The correct answer identifies the client at the highest risk for sudden physiological deterioration. Alcohol withdrawal symptoms typically begin 6 to 8 hours after the last drink and peak between 24 and 72 hours. Anxiety, diaphoresis, and tachycardia (a heart rate of 118 beats/min) are early autonomic signs of withdrawal. Without immediate assessment and administration of cross-tolerant medications (such as benzodiazepines), this client is at high risk for progressing to withdrawal seizures or delirium tremens, which are potentially fatal medical emergencies.

Step-by-Step Solution

1
Analyze each client's clinical presentation to determine physiological stability.
Three clients are physiologically stable or experiencing non-life-threatening conditions, while one client is exhibiting signs of a potentially fatal complication.
Safe prioritization requires identifying the client with the most immediate threat to life, circulation, or risk of severe neurological deterioration.
2
Evaluate the client with a history of heavy alcohol use exhibiting tachycardia, anxiety, and diaphoresis at 48 hours post-admission.
These findings are recognized as early autonomic indicators of acute alcohol withdrawal.
Alcohol withdrawal symptoms typically peak between 24 and 72 hours after the last drink and can rapidly progress to life-threatening withdrawal seizures or delirium tremens without prompt pharmacological intervention.

Key Concept

Prioritizing care for clients experiencing acute substance withdrawal
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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