A nurse is caring for a client experiencing alcohol withdrawal who has been prescribed chlordiazepoxide (Librium). Which assessment finding would be the priority concern requiring immediate intervention?
1Blood pressure reading of 150/90 mmHg
2Mild tremors noted in both hands
3Respiratory rate of 8 breaths per minute✓ 정답
4Anxiety and restlessness observed
해설
Respiratory rate of 8 breaths/min indicates severe respiratory depression from benzodiazepines like chlordiazepoxide, requiring immediate intervention to prevent respiratory failure. Other findings are common in alcohol withdrawal but less urgent.
Clinical Judgment
This question tests Prioritization and monitoring for drug side effects. Chlordiazepoxide is effective for managing alcohol withdrawal symptoms, but Notify HCP! the most dangerous side effect is Respiratory Depression. A respiratory rate of 8 breaths/min is a life-threatening sign that deviates significantly from the normal range (12-20 breaths/min), requiring immediate nursing intervention and notification of the healthcare provider. The other options are typical symptoms of alcohol withdrawal or, like hypertension, require monitoring but are not immediate life threats.
Memory Tip:
When remembering the dangers of benzodiazepines, think of the mnemonic: Benzodiazepines cause Breathing Blues. Especially since patients with alcohol withdrawal already have an unstable central nervous system, they are more vulnerable to respiratory depression when sedatives are administered.
KR vs US:
In Korea, various benzodiazepines besides chlordiazepoxide may be used for patients with alcohol withdrawal. The same is true in the US, but a key characteristic is the highly systematic application of protocols that use the CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) tool to objectively score symptoms and adjust medication dosages based on that score. In Korea, there is a tendency to rely more on the physician's judgment.
임상 시나리오
Clinical Practice Guide
When administering chlordiazepoxide (Librium), the nurse should:
1. Regularly monitor respiratory rate, pattern, depth, and oxygen saturation (SpO2).
2. If signs of respiratory depression (slow, shallow breathing, cyanosis, decreased level of consciousness) appear, immediately stop the medication and report to the medical team.
3. Be familiar with the location and use of benzodiazepine antagonists such as flumazenil (Romazicon).
4. Assess fall risk (due to sedative and muscle relaxant effects).
Caution:
In SATA (Select All That Apply) questions asking for the "highest priority" or what "requires immediate intervention," always choose threats to the ABCs (Airway, Breathing, Circulation) first. Anxiety or tremors are uncomfortable, but respiratory arrest is an immediate risk of death.
핵심 개념
Chlordiazepoxide — A long-acting benzodiazepine sedative used to treat alcohol withdrawal syndrome and anxiety disorders. It increases GABA receptor activity, producing sedative, anti-anxiety, and anticonvulsant effects.
Alcohol Withdrawal Syndrome — A group of symptoms that occur when a person dependent on alcohol suddenly stops or reduces drinking. Tremors, anxiety, agitation, sweating, increased heart rate, and in severe cases, delirium or seizures may appear.
Respiratory Depression — Breathing becomes shallow and slow, leading to insufficient gas exchange in the lungs (oxygen intake and carbon dioxide removal). This is a major life-threatening side effect of central nervous system depressants such as benzodiazepines and opioids.
Benzodiazepine — A class of drugs that acts on GABA-A receptors to produce sedative, anti-anxiety, muscle relaxant, and anticonvulsant effects. Useful for managing withdrawal symptoms, but carries risks of tolerance, dependence, and respiratory depression.
Flumazenil — A selective antagonist used in benzodiazepine overdose. It competitively blocks benzodiazepines from binding to GABA receptors, reversing their effects.