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Zorluk: OrtaSubstance Use and Other Disorders

During an afternoon shift at an inpatient care facility, a 68-year-old client with a documented history of severe alcohol use disorder begins experiencing visual hallucinations, coarse hand tremors, and profound diaphoresis. The client is pacing the room and shouting about insects crawling on the walls. Which actions should the practical nurse (PN) take? Select all that apply.

  1. Remain with the client to provide continuous observation and maintain a safe environment.Cevap
  2. B
    Ask the client, "Why do you think there are insects crawling on the walls?"
  3. C
    Apply soft limb restraints to prevent the client from leaving the room or causing self-injury.
  4. Notify the registered nurse (RN) immediately regarding the client's acute physiological and behavioral changes.Cevap
  5. E
    Document that the client is experiencing expected age-related confusion associated with being in a new facility.
  6. Ensure the room is well-lit to minimize shadows and reduce the risk of sensory misinterpretation.Cevap

Cevap

The correct actions are to remain with the client, notify the registered nurse (RN) immediately, and ensure the room is well-lit.
The correct actions prioritize immediate client safety and the appropriate escalation of care. Remaining with the client provides a safe presence and allows for continuous monitoring during a medical emergency. Notifying the RN is essential because alcohol withdrawal delirium is life-threatening and requires urgent pharmacological intervention that the RN or provider must initiate. Finally, keeping the room well-lit reduces shadows, which helps decrease visual misinterpretations and terrifying hallucinations.

Adım Adım Çözüm

1
Identify the client's clinical presentation and underlying risk factors.
The client has a history of severe alcohol use disorder and is exhibiting hallucinations, tremors, and diaphoresis, which are classic signs of alcohol withdrawal delirium (delirium tremens).
Recognizing acute alcohol withdrawal is critical because it is a life-threatening medical emergency requiring immediate intervention.
2
Determine the priority nursing interventions for a client in acute withdrawal.
The PN must prioritize client safety, physiological stability, and prompt communication with the supervising healthcare team.
The client requires immediate medical management and a safe, modified environment to prevent self-harm or accidental injury during hallucinations.
3
Evaluate the proposed actions against safe PN practice and therapeutic communication standards.
Staying with the client, notifying the RN, and optimizing room lighting are appropriate and safe. Asking "why", using premature restraints, or dismissing the acute confusion as age-related are unsafe and non-therapeutic.
Interventions must fall within the PN scope of practice, prioritize the least restrictive safety measures, and avoid communication blocks.

Anahtar Kavram

Nursing management and safety priorities for acute alcohol withdrawal (delirium tremens).
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Konular

Substance Use and Other Disorders

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