Question

A nurse is caring for a patient 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° C (98.2° F)

1200:
Blood pressure 120/84 mm Hg
Heart rate 96/min
Respiratory rate 20/min
Temperature 37° C (98.6° F)

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 I'm 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 is rigid and jaw is clenched. Pacing and restless.

Complete the following sentence by using the list of options

The patient is at greatest risk for __________ as evidenced by the patient's _________

Answer 1

The patient exhibits signs of alcohol withdrawal syndrome, indicated by changes in vital signs and behavior.

Step-by-step explanation:

The patient is at greatest risk for alcohol withdrawal syndrome as evidenced by the patient's increased heart rate, increased respiratory rate, refusal to eat or drink, staring intently, rigid posture, clenched jaw, pacing, and restlessness.

These symptoms suggest an escalation of vital signs and behaviors which are signs of alcohol withdrawal. This condition can occur in patients with alcohol use disorder who suddenly decrease or stop alcohol consumption and can lead to serious complications if not treated properly.