A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 110 mg/dL (0.11 mg%). Which action by the nurse is most appropriate?
a. Avoid the use of IV fluids.
b. Maintain the patient on NPO status.
c. Administer acetaminophen for headache.
d. Monitor frequently for anxiety, hyperreflexia, and sweating.
ANS: D
The patient's assessment data indicate probable physiologic dependence on alcohol, and the patient is likely to develop acute withdrawal such as anxiety, hyperreflexia, and sweating, which could be life threatening. Acetaminophen is not recommended because it is metabolized by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated patients to prevent Wernicke's encephalopathy, and there is no indication that the patient should be NPO.
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