A client admitted 18 hours after the last alcohol drink has tremor, diaphoresis, BP 168/96, HR 116, and visual hallucinations. Which interventions should the nurse anticipate? Select all that apply.

Select All That Apply

Choose your responses, then check the answer.

1 Restrict the client from any 12-step or peer support contact during withdrawal 2 Give IV thiamine 100 mg before any IV dextrose-containing fluid 3 Administer benzodiazepine using a symptom-triggered (CIWA-Ar based) protocol 4 Use frequent reorientation and a calm low-stimulation environment 5 Implement seizure and fall precautions

Explanation

Symptom-triggered benzodiazepine dosing per CIWA-Ar reduces total benzodiazepine exposure and length of stay compared with fixed schedules. Thiamine 100 mg IV is given BEFORE glucose to prevent Wernicke encephalopathy. Seizure and fall precautions cover withdrawal seizure risk peaking 24-48 hours. Frequent reorientation and low stimulation prevent escalation. Cutting peer/12-step support is harmful — recovery support improves engagement and outcomes.

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A client admitted 18 hours after the last alcohol drink has tremor, diaphoresis, BP 168/96, HR 116, and visual hallucinations. Which interventions should the nurse anticipate? Select all that apply.

Select All That Apply

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