Question

A nurse is caring for a client who has alcohol use disorder

Exhibit 1
Vital Signs
0800

Blood pressure 116/68 mm Hg
Heart rate 80/min
Respiratory rate 14/min
Temperature 36.8 (98.2)
1200

Blood pressure 120/84 mm Hg
Heart rate 96/min
Respiratory rate 20/min
Temperature 37 (98.6)
Exhibit 2
Nurses' Notes
0800
Client alert and oriented to time, place, person, and situation. Visiting with other clients in the dayroom. Attended group session this morning and stated, "I think Im beginning to see what I need to do to get better." Eager to have family visit with partner later this morning

1230
Client attended lunch with other clients but refused to eat or drink today. Staring intently at other clients and nursing staff. Posture rigid and jaw is clenched. Pacing and restless.

Question:
Which of the following actions should the nurse take based on the information provided?

A. Assess the client for signs of alcohol withdrawal
B. Encourage the client to continue attending group sessions
C. Request a prescription for antipsychotic medication
D. Monitor the client's vital signs for signs of hypertensive crisis

Answer 1

The nurse should assess the client for signs of alcohol withdrawal and monitor vital signs closely, as the client's changes in blood pressure, heart rate, respiratory rate, and behavior suggest possible withdrawal symptoms.

Step-by-step explanation:

Alcohol Withdrawal and Vital Sign Monitoring

A client with a history of alcohol use disorder is showing changes in vital signs and behavior that suggest possible alcohol withdrawal. The nurse notes that between 0800 and 1200, the client's blood pressure rose from 116/68 mm Hg to 120/84 mm Hg, heart rate from 80/min to 96/min, and respiratory rate from 14/min to 20/min. Additionally, the client's behavior changed from being alert and oriented to refusing to eat or drink, demonstrating intense staring, rigidity, restlessness, and a clenched jaw. These signs point towards the need for the nurse to:

1. Assess the client for signs of alcohol withdrawal, which may include agitation, elevated vital signs, tremors, and hallucinations.
2. Monitor the client's vital signs carefully for further changes that may indicate the severity and progression of withdrawal symptoms or the potential for a hypertensive crisis.

Group therapy sessions and antipsychotic medications might be helpful at different stages, but the most immediate concerns are assessing for withdrawal symptoms and monitoring vital signs.