A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse anticipate the provider to prescribe?

Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin¹.

Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding⁷⁸.

Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy⁴⁵.

Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin¹¹¹².

Choice A reason : Conducting 15-minute checks can be part of the safety measures for a client at risk of self-harm, but it may not be sufficient for someone who is actively hearing voices commanding self-harm and refusing to engage in safety planning. These checks are less intensive and may not provide the immediate intervention needed to ensure the client's safety¹.

Choice B reason : Encouraging the client to express feelings related to suicide is an important therapeutic intervention that can provide insight into the client's emotional state and risk factors. However, if the client is actively psychotic and not engaging in safety planning, this approach alone may not be enough to ensure immediate safety¹.

Choice C reason : Placing the client on one-to-one observation is the most direct and immediate intervention to ensure safety when a client is experiencing psychotic features and is at risk of self-harm. This level of observation means that the client is never alone, and a staff member is always present to intervene if the client attempts self-harm¹.

Choice D reason : Obtaining an order for locked seclusion can be considered if other less restrictive measures are not sufficient to ensure the client's safety. However, it is generally a last resort due to the potential for negative psychological effects and should only be used when absolutely necessary and when other interventions have failed¹.