A triage nurse in the emergency department is evaluating four clients, each with a history of substance use. Based on the presenting clinical findings, which client should the nurse identify as the highest priority for immediate medical intervention?
- A client who abruptly stopped taking high-dose alprazolam 48 hours ago, presenting with worsening muscle tremors, marked agitation, and a heart rate of 132 beats per minute.Answer
- BA client who last used heroin 24 hours ago, presenting with excessive yawning, rhinorrhea, piloerection, and severe abdominal cramping.
- CA client with chronic alcohol use who had their last drink 8 hours ago, presenting with a mild headache, generalized anxiety, and a blood pressure of 135/85 mmHg.
- DA client who recently inhaled cocaine, currently pacing the triage area, speaking rapidly, and demonstrating hypervigilance without physical aggression.
Answer
The client who abruptly stopped taking high-dose alprazolam 48 hours ago and is experiencing severe muscle tremors, agitation, and a heart rate of 132 beats per minute.
The correct answer identifies the client in acute benzodiazepine withdrawal. Abrupt cessation of central nervous system depressants like alprazolam can lead to severe autonomic hyperactivity, seizures, and death. The presence of worsening tremors and marked tachycardia (132 bpm) indicates that this client is highly unstable and requires immediate medical intervention to prevent status epilepticus.
Step-by-Step Solution
Key Concept
Prioritization of Substance Use Emergencies