# A nurse is assessing a patient who was admitted 48 hours ago for alcohol detoxification. Which assessment finding would be the highest priority concern indicating severe alcohol withdrawal syndrome?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319713  
> language: ko  
> subject: Mental Health

## 문제

A nurse is assessing a patient who was admitted 48 hours ago for alcohol detoxification. Which assessment finding would be the highest priority concern indicating severe alcohol withdrawal syndrome?

## 보기

1. New onset of seizure activity with tonic-clonic movements **✔ 정답**
2. Blood pressure of 160/95 mmHg with heart rate of 110 bpm
3. Visual hallucinations of insects crawling on the skin
4. Tremors of the hands with profuse diaphoresis

**정답: 1**

## 해설

Seizure activity is the most life-threatening complication of alcohol withdrawal, requiring immediate intervention to prevent status epilepticus and death. Other findings like hypertension, hallucinations, and tremors are significant but less urgent.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the nurse's ability to prioritize life-threatening complications of Alcohol Withdrawal Syndrome (AWS). The pathophysiology involves the central nervous system's (CNS) rebound hyperactivity after chronic alcohol (a CNS depressant) is removed. This can progress through stages: autonomic hyperactivity (tremors, tachycardia), perceptual disturbances (hallucinations), and finally, the most severe stage, Delirium Tremens (DTs), characterized by severe autonomic instability, profound confusion, and a high risk of seizures.

**Answer Rationale**: Key Point! The highest priority is always given to findings that indicate an immediate threat to life or airway/breathing/circulation (ABCs). A new onset of seizure activity is the most critical sign here. Seizures in AWS can be severe, lead to status epilepticus, cause respiratory compromise, injury, and are a hallmark of impending DTs, which has a significant mortality rate if untreated. This requires immediate pharmacological intervention (e.g., benzodiazepines) and safety measures.

**Distractor Analysis**: Watch out for confusion! While all other findings are part of AWS and require nursing intervention, they are not the *highest* priority in this context.

• Option 2 (BP 160/95, HR 110): This indicates autonomic hyperactivity (Stage 1-2 withdrawal) and is serious but not immediately life-threatening on its own. It signals the need for medication (e.g., benzodiazepines) to prevent progression.

• Option 3 (Visual hallucinations): Also known as alcoholic hallucinosis. This is a sign of more severe withdrawal (Stage 2) but, without accompanying seizures or severe autonomic instability, is less immediately dangerous than a seizure.

• Option 4 (Tremors, diaphoresis): These are classic early signs of AWS (Stage 1). They are significant and require monitoring and treatment to prevent progression, but they are not the most acute life threat.

**Related Concepts**: The priority framework (ABCs, Maslow's Hierarchy) is essential. Seizures directly threaten airway, breathing, and circulation. NCLEX often tests the progression of AWS and the nurse's role in using assessment tools like the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) to guide medication administration and prevent complications.

Concept Summary
• **Alcohol Withdrawal Timeline**: Symptoms can begin 6-24 hours after last drink, peak at 24-72 hours, and DTs risk is highest 48-96 hours post-cessation.

• **Priority Complications**: Seizures > Delirium Tremens (autonomic storm) > Severe hallucinations/agitation > Autonomic hyperactivity (HTN, tachycardia) > Mild tremors/anxiety.

• **First-Line Treatment**: Benzodiazepines (e.g., lorazepam, diazepam) are the cornerstone for managing AWS and preventing seizures/DTs.

Side-by-Side Comparison!

| Symptom | Stage of AWS | Clinical Significance & Priority |
| --- | --- | --- |
| Tremors, Tachycardia, Hypertension | Stage 1 (Early Withdrawal) | Signals need for treatment to prevent progression. Moderate priority. |
| Hallucinations (visual/tactile), Agitation | Stage 2 (Alcoholic Hallucinosis) | Indicates worsening withdrawal. High priority for safety and medication. |
| Generalized Tonic-Clonic Seizures | Stage 2/3 (Often precedes DTs) | Highest priority. Life-threatening; requires immediate intervention. |
| Delirium Tremens (DTs): Confusion, fever, severe autonomic instability | Stage 3 (Late Withdrawal) | Medical emergency. High mortality if untreated. Highest priority. |

Anatomy, Physiology & Pharmacology Points
• **Pathophysiology**: Chronic alcohol enhances inhibitory GABA activity and suppresses excitatory NMDA receptors. Sudden cessation causes a rebound: reduced GABA inhibition and excessive NMDA activation, leading to CNS hyperexcitability (seizures, agitation).

• **Drug Mechanism**: Benzodiazepines (e.g., lorazepam) work by potentiating GABA, directly countering the hyperexcitable state to prevent and treat seizures and DTs.

Memory Tips
• **Mnemonic for AWS Stages**: "**T**hings **H**appen **S**oon **D**angerously" – **T**remors, **H**allucinations, **S**eizures, **D**Ts.

• **Think "S" for Seizure and Safety**: The "S" in "Severe" withdrawal stands for Seizure, which is the Signal for immediate action.

High-Frequency NCLEX Topics
AWS is a classic NCLEX priority question. The exam tests: 1) Recognizing the timeline of symptoms, 2) Using the CIWA-Ar scale, 3) Knowing that benzodiazepines are first-line treatment, and 4) **Prioritizing seizure and DTs as medical emergencies** over other withdrawal symptoms.

Watch Out for Question Variations!
• Instead of "highest priority concern," it could ask: "The nurse should prepare to administer which medication first?" (Answer: A benzodiazepine).

• The scenario might give a CIWA-Ar score of 25 and ask for the appropriate nursing action (e.g., administer PRN medication per protocol).

• It could combine AWS with other conditions, asking: "Which patient should the nurse assess first?" A patient with AWS reporting "bugs on the wall" vs. a patient with AWS having a seizure.

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are the nurse on a medical-surgical unit. Mr. Johnson, 52, was admitted 48 hours ago for a leg fracture. His history reveals heavy alcohol use, and he is now showing signs of withdrawal—agitation, tachycardia, and now experiencing a generalized tonic-clonic seizure.

**Nursing Intervention Strategy**:

1. **Immediate Safety & Assessment (During Seizure)**: Stay with the patient. Call for help. Lower the bed, raise side rails (padded if available), turn patient to lateral position if possible to maintain airway. Do not restrain or place anything in the mouth. Time the seizure. Assess airway, breathing, and circulation.

2. **Post-Seizure Care**: After movements stop, perform a full neurological assessment (Glasgow Coma Scale (GCS)), check vital signs, provide oxygen, and ensure patient safety in a calm, low-stimulus environment.

3. **Pharmacological Intervention**: Anticipate and prepare to administer IV benzodiazepines (e.g., lorazepam) as ordered per protocol or CIWA-Ar scale to prevent further seizures and progression to DTs.

4. **Ongoing Monitoring**: Continuous cardiac and pulse oximetry monitoring. Frequent vital signs and CIWA-Ar assessments (every 1-4 hours) to guide medication dosing.

**Patient Safety and Precautions**: Seizure precautions are mandatory. Ensure the environment is safe (no sharp objects). Monitor for respiratory depression, a potential side effect of high-dose benzodiazepines. Always use fall precautions due to ataxia and confusion.

Nursing Procedure & Medication Flow
• **CIWA-Ar Assessment**: A systematic tool scoring nausea, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation. Scores >15-20 indicate severe withdrawal requiring aggressive treatment.

• **Benzodiazepine Administration**: Often given IV for rapid effect in acute situations. Lorazepam is common due to its intermediate half-life. Monitor for oversedation and respiratory rate (< 12 breaths/min is a concern).

A Word from Your Senior Nurse
"Seeing a patient have a seizure can be scary, but your calm, quick response is everything. In alcohol withdrawal, a seizure isn't just a neurological event—it's a red flare signaling that the brain is in a dangerous state of hyperexcitability and DTs could be next. Your priority is to protect the patient from injury and get medication on board to calm that storm. Remember, in these situations, you're not just following an order for Ativan; you're preventing a life-threatening complication. This kind of critical thinking and rapid intervention is what makes nursing so vital."

## 핵심 개념

- **Delirium Tremens** — A severe, life-threatening form of alcohol withdrawal characterized by acute confusion, autonomic hyperactivity (fever, tachycardia, hypertension), and visual/tactile hallucinations, typically occurring 48-96 hours after cessation.
- **Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar)** — A validated, 10-item scale used to assess the severity of alcohol withdrawal symptoms and guide medication (typically benzodiazepine) administration to prevent complications.
- **Benzodiazepines** — A class of CNS depressant drugs (e.g., lorazepam, diazepam) that act on GABA receptors; they are the first-line pharmacological treatment for AWS to reduce symptoms and prevent seizures and DTs.
- **Status Epilepticus** — A medical emergency defined as a seizure lasting more than 5 minutes or having two or more seizures without full recovery of consciousness in between. It is a risk during severe alcohol withdrawal.
- **Autonomic Hyperactivity** — Overactivity of the autonomic nervous system, manifesting in AWS as tachycardia, hypertension, diaphoresis (sweating), fever, and tremors. It is a core feature of withdrawal.

## 같은 주제 문제

- [A nurse is caring for a client experiencing alcohol withdrawal. Which assessment finding r…](https://mymerci.kr/pages/nclex_q.php?qn_id=319706)
- [A nurse is caring for a client experiencing alcohol withdrawal. Which nursing intervention…](https://mymerci.kr/pages/nclex_q.php?qn_id=319707)
- [A nurse is caring for a 45-year-old client admitted for alcohol withdrawal who is exhibiti…](https://mymerci.kr/pages/nclex_q.php?qn_id=319708)
- [A nurse is caring for a client experiencing severe alcohol withdrawal symptoms. Which nurs…](https://mymerci.kr/pages/nclex_q.php?qn_id=319709)
- [A nurse is caring for a client experiencing alcohol withdrawal syndrome. Which nursing int…](https://mymerci.kr/pages/nclex_q.php?qn_id=319710)
- [A nurse is assessing a patient admitted for alcohol withdrawal. Which assessment finding w…](https://mymerci.kr/pages/nclex_q.php?qn_id=319711)
- [A nurse is assessing a patient who was admitted 72 hours ago for alcohol withdrawal. Which…](https://mymerci.kr/pages/nclex_q.php?qn_id=319712)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._