A 52-year-old client is recovering on the medical-surgical unit 48 hours after an elective orthopedic surgery. The client suddenly becomes highly agitated, visibly diaphoretic, and exhibits a coarse bilateral hand tremor. Current vital signs reveal a heart rate of 124 bpm, blood pressure of 168/98 mm Hg, and temperature of 100.2°F (37.9°C). The client's spouse arrives and states, "I forgot to bring the home pill bottles, including the clonazepam that my spouse takes three times every day." Which of the following is the priority nursing action?
- AInform the spouse that postoperative anxiety is expected and dim the room lights to promote a calming environment.
- BInstruct the unlicensed assistive personnel (UAP) to perform neurologic checks and monitor vital signs every 15 minutes.
- Initiate seizure precautions and contact the healthcare provider to obtain a prescription for a withdrawal management protocol.Cevap
- DAdminister the prescribed as-needed intravenous opioid analgesic to manage potential untreated surgical pain.
Cevap
The priority action is to initiate seizure precautions and contact the healthcare provider for a withdrawal management protocol.
The client is exhibiting classic signs of acute sedative-hypnotic (benzodiazepine) withdrawal, which typically begins 24 to 72 hours after the last dose. Because abrupt cessation of benzodiazepines can rapidly progress to life-threatening status epilepticus and delirium, the absolute priority is to ensure client safety by implementing seizure precautions and promptly obtaining medical treatment (such as a benzodiazepine taper) to manage the physiological withdrawal.
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Anahtar Kavram
Recognition and emergency management of sedative-hypnotic withdrawal