The nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal symptoms. Which of the following should be the priority action by the nurse?

Choice A reason:
The client experiencing withdrawal symptoms should be monitored, as these symptoms can range from mild to severe. Withdrawal symptoms may include fatigue, depression, and anxiety, which are significant but generally not life-threatening. The nurse should provide supportive care and monitor the client's vital signs and emotional state.

Choice B reason:
If the client is experiencing hallucinations, this indicates a more severe level of withdrawal and possibly the presence of a stimulant-induced psychotic disorder. While hallucinations can be distressing and require intervention, they are not the highest priority when compared to the risk of self-harm or harm to others.

Choice C reason:
The risk for traumatic re-experiencing, or flashbacks, is a concern during withdrawal, particularly if the client has a history of trauma. These experiences can be highly distressing and may lead to further psychological distress. However, the immediate physical safety of the client and others takes precedence.

Choice D reason:
The risk of self-harm or harm to others is the most critical safety concern and must be prioritized. Clients withdrawing from stimulants may exhibit increased agitation, aggression, or impulsivity, which can lead to dangerous behaviors. The nurse must take immediate action to ensure a safe environment, which may include close supervision, the use of restraints, or rapid pharmacological intervention.

Choice A reason:

This hypothesis aligns with the typical motivations seen in factitious disorder, where individuals intentionally produce or exaggerate symptoms of illness in themselves to receive attention, sympathy, and care from medical personnel¹. The nurse should prioritize understanding this behavior to manage the client's care effectively and to avoid unnecessary medical interventions.

Choice B reason:

Similar to choice A, individuals with factitious disorder may induce injury or illness to fulfill a psychological need for attention and validation. Recognizing this motivation is crucial for the nurse to provide appropriate psychological support and to prevent further self-harm.

Choice C reason:

While misdiagnosis or medical error can occur, this is not typically a hypothesis that should be prioritized in the care of a client with factitious disorder. The disorder involves intentional actions by the client, not errors by healthcare providers.

Choice D reason:

Seeking financial gain is more characteristic of malingering than factitious disorder. In factitious disorder, the primary motivation is psychological gratification from playing the patient role, rather than external incentives like financial gain.

Choice E reason:

Factitious disorder involves the intentional production of symptoms without an underlying medical condition. Therefore, this hypothesis would not be a priority in the care of a client with factitious disorder, as the symptoms are not related to a genuine medical condition but are self-induced.