A client admitted for alcohol withdrawal is tremulous, diaphoretic, and reports seeing insects on the wall. Which nursing action is most appropriate?
1Provide a low-stimulation environment by dimming lights and minimizing noise.
2Implement seizure precautions and administer prescribed benzodiazepine therapy.✓ Correct answer
3Offer the client coffee or other caffeinated beverages to help maintain alertness.
4Encourage the client to maintain mobility by ambulating in the hallway with supervision.
Explanation
Severe alcohol withdrawal can cause hallucinations, autonomic instability, and seizures. Seizure precautions and prescribed benzodiazepine therapy are appropriate safety-focused interventions. Leaving the client alone or stimulating with caffeine increases risk.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Severe alcohol withdrawal.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Severe alcohol withdrawal, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Alcohol Withdrawal — A syndrome after reduced alcohol intake that can include tremor, agitation, hallucinations, and seizures.
Seizure Precautions — Safety measures to reduce injury if a seizure occurs.
Benzodiazepine — A medication class commonly used to manage withdrawal symptoms and seizure risk.