A client has been admitted in withdrawal delirium. He is dehydrated and has a bruised, swollen tongue
He is experiencing illusions and auditory hallucinations and is confused. In developing a care plan for this client, what measures should the nurse include to ensure physiologic stability?
1. Applying ice to the tongue
2. Withholding oral fluids
3. Keeping the room dark
4. Monitoring vital signs
ANS: 4
To provide safe care, the nurse must monitor the vital signs to assess for the physiologic life-threatening symptoms of withdrawal. The person can be given food and drink (options 1 and 2), but these are not foremost in the plan. A dark room could be problematic for someone with hallucinations so option 3 is incorrect.
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