A nurse is caring for a client who has alcohol use disorder.
Which of the following findings should indicate to the nurse that the client is experiencing the initial stage of acute withdrawal?

Choice A rationale

A client repeatedly requesting anxiety medication should be assessed, but their behavior does not indicate an immediate safety risk to themselves or others. While their anxiety needs attention, other clients may have more urgent needs. The nurse should acknowledge their request and address it in a timely manner, but not necessarily as the absolute first priority.

Choice B rationale

A client yelling obscenities and throwing clothes is exhibiting escalating and potentially aggressive behavior. This situation poses an immediate risk to the client's safety and the safety of others on the unit. The nurse must intervene promptly to de-escalate the situation, ensure the client's well-being, and prevent potential harm to themselves or others. This behavior indicates a loss of control and requires immediate attention.

Choice C rationale

A client with bipolar disorder who is continuously pacing is displaying psychomotor agitation, which is characteristic of a manic episode. While this behavior warrants assessment and intervention, it does not present the same level of immediate risk as the client who is actively yelling and throwing objects. The pacing client should be monitored and offered interventions to help manage their agitation, but they are not the highest priority in this scenario.

Choice D rationale

A client screaming at other clients in the dayroom is exhibiting aggressive verbal behavior that is disruptive and potentially threatening to others. This situation requires the nurse's intervention to de-escalate the situation, ensure the safety and comfort of the other clients, and address the yelling client's behavior. However, the client actively throwing objects in their room poses a more immediate and direct safety risk.

Choice A rationale: Pupils

Dilated pupils are a common sign of stimulant intoxication, particularly with substances like methamphetamine. Given that the client recently injected an unknown substance, pupil dilation could indicate acute intoxication and require urgent evaluation to prevent potential overdose or complications.

Choice B rationale: Heart rate

A heart rate of 121–124/min is significantly elevated, suggesting tachycardia, which can be related to stimulant use (such as methamphetamine) or withdrawal effects. High heart rates, especially in the context of withdrawal, can increase the risk of arrhythmias or cardiac complications, requiring close monitoring and intervention.

Choice C rationale: Orientation

The client was oriented only to person upon admission, which suggests altered mental status. Substance intoxication or withdrawal can impair cognitive function, decision-making, and awareness, increasing the risk for agitation, confusion, or more severe withdrawal symptoms such as hallucinations or seizures.

Choice D rationale: Respiratory rate

A respiratory rate of 20/min falls within the normal range (typically 12–20 breaths per minute) and does not indicate immediate distress requiring escalation of care.

Choice E rationale: Medical history

While knowing the client’s medical history is important for long-term care planning, it does not require immediate reporting unless the client has a history of conditions that could complicate withdrawal.

Choice F rationale: Oxygen saturation

An oxygen saturation of 98% on room air is within normal limits, meaning oxygenation is adequate. There is no immediate concern requiring intervention based on this finding.