37 Addiction: Alcohol use disorder

The nurse is caring for a client admitted for alcohol addiction. Which of the following questions is the priority at this time? "Does anyone else in your family also suffer from alcohol addiction?" "Have you ever been to treatment for this addiction?" "Have you ever purposefully hurt yourself or tried to end your life?" "Have you had any legal consequences because of your addiction?"

"Have you ever purposefully hurt yourself or tried to end your life?" Self-harm and suicide assessment is critical for clients who suffer from alcohol addiction. This client may require a sitter and additional support if they have suicidal ideation.

After being admitted as an inpatient for treatment of substance abuse, a client becomes confused and disoriented and is demonstrating tachycardia, sweating, and tremor. Which nursing intervention is mostappropriate for management of this client? Administer benzodiazepines to control symptoms Reduce fluid intake to prevent aspiration Obtain an order to begin monitoring pulse oximetry Provide warm blankets to promote client comfort

Administer benzodiazepines to control symptoms This client is displaying symptoms of Delirium Tremens, or DTs. This is a condition that develops in response to withdrawal from alcohol, usually 48 to 72 hours after cessation of alcohol intake. The nurse should monitor the client's vital signs and provide a calm environment during this difficult transition.

The nurse is caring for a client who presents to the ER with complaints of a fall with a laceration to the right arm. The client is slurring their speech. All vital signs are within normal limits. Which substance should be suspected in this client? Heroin Alcohol Methamphetamine Cocaine

Alcohol A client who has abused alcohol presents with slurred speech. They will have the smell of alcohol and often sustain injuries while intoxicated.

A client has orders for lorazepam administration, seizure precautions, and a banana bag. The nurse recognizes that this client is at risk for which of the following conditions? Alcohol withdrawal Sundowner's syndrome Hypoactive delirium Epilepsy

Alcohol withdrawal Therapeutic management for a client with alcohol withdrawal includes IV nutrient replacement with thiamine, sometimes called a banana bag, seizure precautions, prn ativan, and a CIWA assessment on regular intervals to assess for alcohol withdrawal.

A client is undergoing acute alcohol withdrawal and is experiencing delirium tremens. Which nursing diagnosis would most likely be associated with this condition? Impaired Urinary Elimination Ineffective Thermoregulation Activity Intolerance Readiness for Enhanced Nutrition

Ineffective Thermoregulation Delirium tremens can develop as part of acute alcohol withdrawal as the body is undergoing detoxification. Symptoms include delirium, sweating, fever, restlessness, seizures and increased pulse and breathing. The delirium usuall peaks between 48 to 72 hours after the client's last drink, and can last for two to three days.

The nurse is caring for a client who is an alcoholic with a history of seizures while going through withdrawals. The nurse is setting up the room and implementing seizure precautions. Which of the following does the nurse ensure is included in the client's plan of care? Call light within reach Padded side rails Head of bed at 45 degrees PRN pain medication ordered

Padded side rails Seizure precautions include padding side rails, making sure suction is set up, and anti-seizure medications are ordered in the clients MAR. For the client, make sure they wear non-constrictive clothing and to be cautious with PO intake.

A client is admitted to the floor from the ER for Ulcerative Colitis complicated with infection. The client is slurring their words and stumbling. The nurse notes empty mini vodka bottles in the client belonging bag. The client reports that they drink every day and asks the nurse to get them more vodka. What is the nurse's priority at this time? Place patient on a withdrawal protocol Get a 12-lead EKG (ECG) Apply soft wrist restraints for safety Administer IV antibiotics

Place patient on a withdrawal protocol Any client who drinks daily and is admitted to the hospital is at risk for alcohol withdrawal (due to no longer having access to alcohol). The priority is to get this client on an alcohol withdrawal protocol as soon as possible so that the nurse can be prepared with medications.

A nurse arrives at work in the psychiatric unit and is given the assignments for the day. The nurse has a client who is experiencing delirium tremens after alcohol withdrawal and needs medication, a client who will be undergoing ECT later that day, a client with obsessive-compulsive disorder who has not had breakfast yet, and a client who needs to go to eating disorder group therapy. Which client should the nurse see first? The client going to group therapy The client receiving ECT later The client with delirium tremens The client who needs breakfast

The client with delirium tremens A nurse must prioritize care to treat the clients with the highest needs first. In this situation, the client who is suffering from delirium tremens (DTs) may be hemodynamically unstable and should be seen first.

While working with a client who is experiencing acute alcohol withdrawal, a nurse performs an assessment by asking the client to drink a glass of water. Which bestexplains the significance of this test? To see if the client has polydipsia To assess the client's cognitive ability To check for hand tremor in the client To determine if the client can follow directions

To check for hand tremor in the client Acute alcohol withdrawal can cause significant physical effects for the client which the nurse must assess and document. One method of assessing tremor is to ask the client to drink a glass of water. If the client's handshakes while drinking the water, the nurse can document that the client is experiencing tremor as part of alcohol withdrawal.

The nurse is working in the emergency department caring for a client with delirium tremens and severe alcohol withdrawal. Which question is the priority? Do you go to AA? When was your last drink and how much do you usually drink? Have you stopped for good? Has this ever happened before when you tried to stop?

When was your last drink and how much do you usually drink? Alcohol withdrawal syndrome typically worsens over a period of 2-3 days. The nurse must find out when the client took their last drink in order to anticipate and plan care for the client during withdrawals. These can be life-threatening with symptoms that must be managed medically.