A client who stopped heavy alcohol use 24 hours ago is tremu… | MyMerci
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Mental Health ConceptsPSI
Question
A client who stopped heavy alcohol use 24 hours ago is tremulous, diaphoretic, anxious, and reports seeing insects on the wall. Which action should the nurse anticipate?
1Administer a prescribed antipsychotic to control visual hallucinations.
2Encourage the client to drink caffeinated beverages to stay awake and alert.
3Administer prescribed benzodiazepine and maintain seizure precautions.✓ Correct answer
4Obtain an order for thiamine and administer it before other medications.
Explanation
The client is exhibiting signs of alcohol withdrawal with hallucinations, which can progress to delirium tremens and seizures. Administering a prescribed benzodiazepine (option 3) is the priority to reduce symptom severity and prevent seizures. Seizure precautions are also necessary. Option 1 (antipsychotic) is not the first choice because antipsychotics can lower the seizure threshold, increasing the risk in alcohol withdrawal. Option 2 (caffeine) would worsen anxiety and tremors. Option 4 (thiamine) is important to prevent Wernicke-Korsakoff syndrome, but it is not the immediate priority over controlling acute withdrawal symptoms with benzodiazepines.