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Difficulty: HardChemical and Other Dependencies / Substance Use Disorders

A 54-year-old client is admitted to the medical unit with an acute exacerbation of heart failure. The client's current vital signs are blood pressure 158/96 mm Hg, heart rate 108/min, and temperature 37.6°C (99.7°F). The client appears mildly agitated and is frequently picking at the bed linens. During the admission assessment, the client states, "I drink a half-liter of vodka every day, but I haven't had a drink since yesterday morning. Please do not tell my healthcare provider; I do not want them to judge me." Which action is the most appropriate for the nurse to take?

  1. A
    Instruct the unlicensed assistive personnel (UAP) to perform hourly clinical withdrawal assessments to ensure rapid detection of worsening symptoms.
  2. B
    Assure the client that their disclosure will remain confidential to build a therapeutic rapport, but discuss the cardiac risks of alcohol use.
  3. C
    Document the vital signs and alcohol use history, and plan to reassess the client's neurological status during the next scheduled rounds.
  4. Explain to the client that the healthcare provider must be informed to ensure safe medical care and immediately initiate alcohol withdrawal precautions.Answer

Answer

Explain to the client that the healthcare provider must be informed to ensure safe medical care and immediately initiate alcohol withdrawal precautions.
The client is at high risk for complicated alcohol withdrawal, including seizures and delirium tremens, as it has been over 24 hours since their last drink. Furthermore, the client is already exhibiting early signs of autonomic hyperactivity (hypertension, tachycardia) and neurological irritability (agitation, picking at linens). The nurse must prioritize client safety by communicating this critical information to the healthcare provider to obtain appropriate prescriptions and immediately implementing withdrawal and seizure precautions. The nurse should communicate this necessity to the client therapeutically, validating their feelings of fear while maintaining firm safety boundaries.

Step-by-Step Solution

1
Analyze the client's vital signs and behavior in conjunction with their self-reported history.
The client has hypertension, tachycardia, mild agitation, and tactile disturbances (picking at linens), and their last heavy alcohol intake was over 24 hours ago.
Recognizing early physiological and behavioral indicators of withdrawal is critical to preventing life-threatening complications like status epilepticus or delirium tremens.
2
Evaluate the client's request for confidentiality regarding their substance use.
The nurse determines that keeping this secret would directly endanger the client's life, as pharmacological intervention is necessary.
Patient safety supersedes the request for confidentiality when the withheld information poses a direct and immediate threat to the client's well-being.
3
Determine the priority nursing action based on the assessment and ethical principles.
The nurse must therapeutically inform the client that the provider will be notified, and immediately implement withdrawal and seizure precautions.
Immediate action ensures the provider can prescribe appropriate medical management (e.g., benzodiazepines) while keeping the client in a safe, monitored environment.

Key Concept

Management and Prioritization of Acute Alcohol Withdrawal
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Topics

Chemical and Other Dependencies / Substance Use Disorders

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