A hospitalized client diagnosed with alcohol use disorder believes spiders are spinning webs in the room to entrap him. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated?
Keep the room dimly lit
One-on-one supervision
Force fluids
Check the patient every 15 minutes
The Correct Answer is B
A. A dimly lit room can increase misperceptions and hallucinations, worsening fear.
B. The client is experiencing alcohol withdrawal delirium with hallucinations, agitation, and high risk for injury. Continuous monitoring ensures safety and allows immediate intervention.
C. Hydration is important, but it is not the priority compared to preventing injury during hallucinations.
D. Intermittent checks are not enough; the client requires continuous supervision for safety.
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Related Questions
Correct Answer is C
Explanation
A. This focuses on problem-solving rather than acknowledging the patient’s feelings, which is not empathy.
B. This expresses the nurse’s feelings, not the patient’s, so it reflects sympathy rather than empathy.
C. This statement acknowledges the patient’s emotional experience and communicates understanding from the patient’s perspective, which demonstrates empathy.
D. This is judgmental and dismissive, showing neither empathy nor support.
Correct Answer is B
Explanation
A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.
B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.
C. This is judgmental and blaming, which is not therapeutic and may increase hostility.
D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.
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