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?
- A client with chronic alcohol dependence demonstrating diaphoresis, a resting heart rate of 118 beats per minute, and mild agitation one day post-admission.Cevap
- BA client with heroin dependence reporting severe abdominal cramping, yawning, and rhinorrhea two days after their last use.
- CA client with a history of methamphetamine use who is exhibiting hypersomnolence and a depressed mood following a recent binge.
- DA client with prescription benzodiazepine dependence who is persistently requesting their scheduled taper dose thirty minutes early.
Cevap
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.
Adım Adım Çözüm
Anahtar Kavram
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).