The client who is experiencing alcohol withdrawal has a temperature of 100.6° F, pulse of 112 beats/minute, and BP 180/102 mm Hg. What would the nurse anticipate doing first?
A) Encourage the client to rest.
B) Administer benzodiazepine as ordered.
C) Monitor for any further changes.
D) Provide emotional support.
B
Feedback:
The standardized symptom withdrawal flow sheet, Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) as well as the Rule of One Hundreds are indicators of escalating withdrawal. The rise in these vital signs suggests the need for sedative medication. Monitoring hourly vital signs and further changes would be appropriate. Rest and emotional support can be helpful.
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