In anticipation of a patient's alcohol withdrawal symptoms, the nurse will perform which actions? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Recognize that hallucinations are common and reorient the patient.
2. Prepare for seizures that might occur within the first 12 hours of admission.
3. Frequently assess vital signs.
4. Have a sitter present to monitor any attempt by the patient to escape.
5. Prevent, recognize, and treat symptoms while providing a safe environment.
1,2,3
Rationale 1: The nurse will assess for hallucinations and orient the patient to reality as needed during alcohol withdrawal syndrome.
Rationale 2: Alcohol withdrawal seizures commonly occur and the nurse should prepare for this within 6 to 48 hours of the last intake of alcohol.
Rationale 3: The nurse will continually monitor the patient's vital signs during alcohol withdrawal syndrome.
Rationale 4: This is not appropriate in the Critical Care environment because the nurse/ patient ratio in this environment is usually 1–2 patients per nurse. This ratio allows for close assessment and monitoring of the patient experiencing alcohol withdrawal syndrome.
Rationale 5: The goals of management for alcohol withdrawal include preventing, recognizing, and treating symptoms while providing a safe environment for the patient.
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