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Zorluk: ZorChemical and Other Dependencies / Substance Use Disorders

A nurse is caring for a client who was admitted 72 hours ago for a severe respiratory infection. The client suddenly becomes extremely agitated, exhibits profuse diaphoresis, and frantically states, "There are spiders crawling all over the walls!" The client's spouse reports that the client usually drinks a pint of vodka daily but abruptly stopped on the day of admission. Arrange the following nursing actions in the correct prioritized sequence from first to last.

  1. 1Remain with the client and call for immediate staff assistance.
  2. 2Assess the client's airway patency and current vital signs.
  3. 3Administer the prescribed rapid-acting intravenous benzodiazepine.
  4. 4Verify that bedside suction and oxygen equipment are set up and functioning.
  5. 5Decrease environmental stimuli by dimming the lights and speaking softly.

Cevap

The correct sequence is to first remain with the client and call for help, followed by assessing airway and vital signs, then administering the intravenous benzodiazepine, establishing bedside seizure precautions, and finally decreasing environmental stimuli.
The sequence follows standard NCLEX prioritization frameworks: Safety first (calling for help while staying with the client), followed by the Nursing Process (assessing vital signs before intervening), followed by Maslow's Hierarchy of Needs (treating the acute physiological threat with medication, preparing for physiological complications like seizures, and finally addressing the environmental/psychosocial needs).

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1
Ensure immediate safety (Remain with the client and call for assistance).
The client is protected from sudden self-harm and additional staff are available to assist.
In acute delirium tremens, the client is highly unpredictable. A nurse must never leave an acutely delirious and hallucinating client alone.
2
Assess physiological status (Assess airway and vital signs).
Baseline autonomic stability is evaluated.
Applying the nursing process, assessment must precede intervention to determine the extent of tachycardia, hypertension, and respiratory status.
3
Implement primary treatment (Administer IV benzodiazepine).
Central nervous system irritability is suppressed.
Pharmacological therapy is the definitive treatment for severe alcohol withdrawal to prevent progression to seizures or cardiovascular collapse.
4
Prevent complications (Verify suction and oxygen).
Seizure precautions are strictly enforced.
Even with medication, the risk of seizures remains high. Preparing the environment for a potential airway emergency is the next highest physiological priority.
5
Provide psychosocial milieu management (Decrease environmental stimuli).
Sensory triggers for hallucinations are minimized.
Once life-threatening physiological and safety priorities are addressed, calming the environment addresses the client's psychological distress.

Anahtar Kavram

Prioritization in acute alcohol withdrawal (Delirium Tremens) utilizing the Safety and Nursing Process (ADPIE) frameworks.
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Konular

Chemical and Other Dependencies / Substance Use Disorders

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