A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
Obtain a blood specimen.
Implement seizure precautions.
Perform a neurological exam.
Insert an IV access site.
The Correct Answer is B
Choice A reason: Obtaining a blood specimen is important to assess electrolyte levels, liver function, or alcohol levels, but it is not the first priority in acute alcohol withdrawal. Immediate safety concerns, such as preventing seizures, take precedence.
Choice B reason: Acute alcohol withdrawal carries a high risk of seizures, which can be life-threatening. Implementing seizure precautions, such as ensuring a safe environment and having emergency medications available, is the first priority to protect the client from harm.
Choice C reason: Performing a neurological exam is valuable to assess the client’s mental status and neurological function, but it is not the first action. Addressing immediate risks like seizures is more urgent in the acute phase of withdrawal.
Choice D reason: Inserting an IV access site is important for administering fluids or medications, such as benzodiazepines, to manage withdrawal symptoms. However, ensuring seizure precautions are in place is a higher priority to address immediate safety risks.
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Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:Tremors, particularly in the hands, are a common symptom of alcohol withdrawal, often appearing within hours of the last drink. They are caused by the nervous system’s hyperexcitability due to the absence of alcohol’s depressant effects, making this a key manifestation to include in teaching.
Choice B reason:Polyphagia, or excessive hunger, is not a typical symptom of alcohol withdrawal. Withdrawal is more commonly associated with loss of appetite or nausea due to gastrointestinal distress and nervous system dysregulation, so this should not be included in the teaching.
Choice C reason:Nystagmus, an involuntary eye movement, can occur in alcohol withdrawal, particularly in severe cases or during delirium tremens. It is a neurological symptom resulting from the brain’s response to withdrawal, making it appropriate to include in the teaching.
Choice D reason:Seizures are a serious and potentially life-threatening complication of alcohol withdrawal, often occurring within 12 to 48 hours after the last drink. Educating the client about this risk is critical, as it underscores the need for medical supervision during withdrawal.
Choice E reason:Illusions, or misinterpretations of sensory stimuli, are common in alcohol withdrawal, especially during severe stages like delirium tremens. These perceptual disturbances should be included in the teaching to prepare the client for possible symptoms.
Correct Answer is A
Explanation
Choice A reason: Allowing the client to describe the event in their own words is essential for initial assessment, evidence collection, and emotional support.
Choice B reason: A bed bath would destroy physical evidence needed for forensic examination.
Choice C reason: Discussing self-defense techniques at this time is inappropriate, as the focus should be on immediate safety, support, and care.
Choice D reason: Photographs may be taken, but the nurse should not present them as required for police reporting, as this can increase trauma and coercion.
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