Examkin

Soru

Zorluk: OrtaChemical and Other Dependencies / Substance Use Disorders

While working at a community homeless shelter, a nurse evaluates a resident who abruptly stopped drinking heavy amounts of liquor two days ago. The resident is currently experiencing profuse sweating, coarse hand tremors, and agitated visual hallucinations. Which of the following actions should the nurse take? (Select all that apply)

  1. Arrange for immediate emergency medical transport to a hospital.Cevap
  2. Remain continuously with the resident in a quiet, safe area.Cevap
  3. C
    Ask the resident, "Why did you decide to stop drinking without seeking medical help?"
  4. D
    Document that the resident is experiencing mild withdrawal and encourage increased oral fluid intake.
  5. E
    Direct the shelter's unlicensed assistive personnel (UAP) to monitor the resident's vital signs every 15 minutes.

Cevap

The nurse should arrange for immediate emergency medical transport to a hospital and remain continuously with the resident in a quiet, safe area.
Severe alcohol withdrawal, known as delirium tremens, typically peaks 48 to 72 hours after the last drink and presents with autonomic hyperactivity, severe tremors, and hallucinations. Because this is a medical emergency capable of causing fatal arrhythmias or seizures, the nurse's priority in a community setting is to activate emergency services for transport to an acute care facility while maintaining continuous supervision to ensure client safety.

Adım Adım Çözüm

1
Assess the severity of the client's clinical presentation and timeline.
The client has a history of heavy drinking, stopped 48 hours ago, and now has hallucinations, diaphoresis, and tremors.
These findings are classic indicators of delirium tremens, a severe and potentially fatal complication of alcohol withdrawal.
2
Determine the safest immediate intervention based on the environment.
Since the client is at a community shelter, they require a higher level of care. Emergency transport must be initiated.
The shelter lacks the necessary resources (e.g., intravenous medications, cardiac monitoring) to manage a life-threatening withdrawal.
3
Establish immediate safety measures while awaiting transport.
The nurse stays with the client to provide continuous observation in a low-stimulus setting.
Continuous presence prevents self-injury during hallucinations and agitation while waiting for the ambulance.

Anahtar Kavram

Management of Severe Alcohol Withdrawal in Community Settings
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Konular

Chemical and Other Dependencies / Substance Use Disorders

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