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Zorluk: OrtaChemical and Other Dependencies / Substance Use Disorders

A client arrives at the behavioral health center for inpatient treatment of major depressive disorder. During the intake interview, the individual mentions consuming a 'couple of drinks' nightly to manage insomnia, with the most recent beverage consumed approximately 12 hours prior. The client currently exhibits restlessness, continuous pacing, and complains of nausea along with a mild headache. What is the priority nursing action at this time?

  1. Initiate a standardized alcohol withdrawal assessment protocol.Cevap
  2. B
    Administer a prescribed as-needed analgesic to treat the headache.
  3. C
    Delegate vital sign monitoring to the psychiatric technician.
  4. D
    Ask the client why they feel dependent on alcohol for sleep.

Cevap

The priority action is to initiate a standardized alcohol withdrawal assessment protocol.
The client's history of daily alcohol consumption, combined with the timeline of their last drink and current symptoms (restlessness, nausea, headache), strongly suggests the onset of early alcohol withdrawal. Using the nursing process, the priority is to formally assess the severity of these physiological symptoms using a validated scale (such as CIWA-Ar) to determine the need for medication and safety precautions.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and timeline.
The client has a history of daily alcohol use, consumed their last drink 12 hours ago, and is now showing restlessness, pacing, nausea, and headache.
Establishing the timeline of last substance use is critical for predicting the onset of withdrawal symptoms.
2
Correlate the findings with known substance use disorder pathophysiology.
The symptoms align perfectly with the early stages of alcohol withdrawal, which typically begins 6 to 24 hours after cessation.
Recognizing early withdrawal prevents progression to severe complications like seizures or delirium tremens.
3
Determine the priority nursing intervention based on the nursing process.
Assessment is the first step. The nurse must formally evaluate the severity of the withdrawal using a validated tool.
A standardized assessment guides the appropriate administration of pharmacological treatments.

Anahtar Kavram

Recognizing and assessing early signs of alcohol withdrawal
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Konular

Chemical and Other Dependencies / Substance Use Disorders

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