A client on an inpatient unit is 18 hours after the last alcohol intake and is tremulous, diaphoretic, and reporting visual hallucinations. Which nursing action is most appropriate?
1Initiate withdrawal protocol and seizure precautions as prescribed.✓ Correct answer
2Encourage the client to walk alone to reduce agitation.
3Explain that hallucinations mean the client is not really withdrawing.
4Withhold prescribed benzodiazepines until the client sleeps.
Explanation
Tremors, diaphoresis, and hallucinations suggest significant alcohol withdrawal and risk for seizures or delirium tremens. The nurse should initiate the prescribed withdrawal protocol and safety precautions. Ambulating alone and withholding indicated medication can increase harm.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Alcohol withdrawal safety.
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 Alcohol withdrawal safety, 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 that can occur after stopping or reducing heavy alcohol use.
Seizure Precautions — Safety measures used for clients at risk for seizures.
Delirium Tremens — A severe form of alcohol withdrawal with confusion, autonomic instability, and hallucinations.