The nurse is assessing patients for impending alcohol withdrawal. The nurse assesses the patient with which of the following conditions as a priority?
a. Pulse, 58 beats/min; and BP 100/60
b. Pulse, 118 beats/min; and BP 160/90
c. Dozing off in chair and not recognizing staff
d. Reporting muscle aches and frequent stumbling
B
Manifestations of alcohol withdrawal are elevated blood pressure, elevated pulse, and autonomic hyperactivity. In addition, fever; increased hand tremors; insomnia; nausea and vomiting; tran-sient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures may occur. The nurse should see the hypertensive, tachycardic patient as the priority.
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