간호사가 음주를 중단한 대상자의 입원 기록을 검토합니다. 심각하거나 복합적인 금단 증상을 시사하여 즉각적인 추적 관찰이 필요한 소견은 무엇입니까? 고위험 소견을 강조하세요.

Nurses' Notes 0700: The client reports the last alcohol use occurred about 36 hours ago. The admission history states that the client slept poorly and woke several times overnight. The client is anxious but answers questions appropriately. A prior record shows a generalized seizure during alcohol withdrawal two years ago. At 0730, the client eats half of breakfast without vomiting. The client follows one-step directions and accepts oral fluids. At 0830, the client remains oriented to person, place, date, and situation. The nurse administers medication according to the withdrawal protocol. At 0930, pulse is 126/min with heavy sweating despite treatment, and blood pressure is 174/102 mm Hg. The client reports mild sensitivity to hallway noise. At 1000, the client walks with assistance and follows safety instructions. The nurse documents that the resting pulse was 82/min during the initial assessment. At 1130, the client develops new disorientation and reports seeing insects on the wall. The client states that appetite is better than it was yesterday. Seizure precautions and close observation are continued.