Y tá xem xét hồ sơ nhập viện của một bệnh nhân đã ngừng uống rượu. Những phát hiện nào cần theo dõi ngay lập tức vì nghi ngờ cai rượu nặng hoặc có biến chứng? Đánh dấu các phát hiện có nguy cơ cao.

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.