A nurse on a mental health unit is assisting with the care of a client.

Exhibits

The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.

A. Administer a benzodiazepine to the client: While benzodiazepines may be useful for managing anxiety, the first step in caring for a client with a dissociative disorder is to build a trusting relationship. Medications should not be prioritized over establishing rapport.
B. Establish rapport with the client: Building rapport is crucial in creating a safe environment for the client. It allows the nurse to gain the client’s trust, facilitating effective communication and treatment. A strong therapeutic alliance is essential for the client's willingness to engage in further interventions.
C. Teach the client grounding techniques: While grounding techniques can be beneficial for clients experiencing dissociation, they are most effective when the client feels safe and supported. Establishing rapport first will help the client be more receptive to learning and practicing these techniques.
D. Educate the client about their disorder: Education is important, but it should come after establishing a trusting relationship. The client may not be open to education about their disorder until they feel comfortable with the nurse and the therapeutic process.

A. Stage 2 (moderate): In this stage of alcohol withdrawal, symptoms may include increased anxiety, tremors, and elevated vital signs, but hallucinations and severe disorientation are not typically present. The client's current condition exceeds the expectations of moderate withdrawal, indicating a more severe level.
B. Stage 1 (mild): Mild withdrawal symptoms are generally characterized by anxiety, insomnia, and mild tremors. The presence of hallucinations, significant changes in vital signs, and severe disorientation suggests that the client is experiencing more than just mild withdrawal symptoms.
C. Stage 3 (severe): Severe alcohol withdrawal is characterized by the presence of hallucinations, severe agitation, confusion, and autonomic instability, as indicated by the client's elevated blood pressure and heart rate. The client’s experience of seeing spiders and disorientation about their location indicates severe withdrawal, which may lead to complications like delirium tremens if not properly managed.
D. The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal: While hallucinations can be indicative of a psychotic disorder, the context of recent alcohol use and the accompanying withdrawal symptoms strongly suggest that the client is experiencing severe alcohol withdrawal rather than a separate psychotic disorder.