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Difficulty: MediumChemical and Other Dependencies / Substance Use Disorders

A nurse on a dual-diagnosis unit is evaluating several clients who were recently admitted. Which client presentation requires the most immediate priority action by the nurse?

  1. A client with chronic alcohol dependence demonstrating diaphoresis, a resting heart rate of 118 beats per minute, and mild agitation one day post-admission.Answer
  2. B
    A client with heroin dependence reporting severe abdominal cramping, yawning, and rhinorrhea two days after their last use.
  3. C
    A client with a history of methamphetamine use who is exhibiting hypersomnolence and a depressed mood following a recent binge.
  4. D
    A client with prescription benzodiazepine dependence who is persistently requesting their scheduled taper dose thirty minutes early.

Answer

The client with chronic alcohol dependence demonstrating diaphoresis, a resting heart rate of 118 beats per minute, and mild agitation requires the most immediate priority action.
The correct answer is the client exhibiting signs of early alcohol withdrawal. Alcohol withdrawal can cause severe, life-threatening complications including withdrawal seizures and delirium tremens. Symptoms such as autonomic hyperactivity (tachycardia, diaphoresis) and agitation occurring a day after admission indicate the onset of withdrawal and require urgent pharmacological intervention to prevent dangerous progression.

Step-by-Step Solution

1
Analyze the presentations of all four clients to determine the physiological risk associated with their specific substance use disorder or withdrawal syndrome.
Alcohol withdrawal carries a risk of fatal complications, whereas opioid and stimulant withdrawal are typically not physiologically life-threatening.
Safe prioritization requires identifying the client with the highest risk for acute physiological instability or death.
2
Evaluate the specific objective symptoms presented by the client with alcohol dependence.
Diaphoresis, tachycardia (heart rate of 118), and agitation are classic indicators of autonomic hyperactivity associated with early alcohol withdrawal.
Early recognition of these signs is critical to initiate medical treatment (e.g., a benzodiazepine protocol) before the condition progresses to severe withdrawal seizures or delirium tremens.

Key Concept

Alcohol withdrawal is a medical emergency that can progress to life-threatening complications, requiring immediate prioritization and pharmacological intervention over uncomfortable but non-fatal withdrawal syndromes (such as opioids).
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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