The nurse is caring for a patient who is withdrawing from alcohol. The patient is restless and reports seeing snakes on the ceiling. Vital signs are as follows: blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min
What should the nurse do first?
a. Administer an antihypertensive agent as ordered.
b. Administer a dose of lorazepam (Ativan).
c. Teach the patient a relaxation technique.
d. Search the patient's room for hidden alcohol.
ANS: A
According to Maslow's hierarchy, physiological symptoms must be attended to first. The patient's blood pressure is at an unsafe level. Once the patient's blood pressure is under control, then Ativan and relaxation may be helpful. Searching the room for alcohol is occasionally necessary, but a patient who has withdrawal symptoms is not likely using alcohol.
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