# A nurse is assessing a client with alcohol withdrawal in the emergency department. Which assessment finding would indicate the most serious complication requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=319721 > language: ko > subject: Mental Health ## 문제 A nurse is assessing a client with alcohol withdrawal in the emergency department. Which assessment finding would indicate the most serious complication requiring immediate intervention? The nurse observes the client becoming increasingly agitated with tremors, diaphoresis, and reports of seeing insects crawling on the walls. ## 보기 1. Blood pressure 150/90 mmHg with heart rate 110 bpm 2. Visual hallucinations with severe agitation and disorientation **✔ 정답** 3. Nausea and vomiting with decreased appetite 4. Mild tremors of hands with anxiety and restlessness **정답: 2** ## 해설 Visual hallucinations with severe agitation and disorientation indicate delirium tremens, the most serious complication of alcohol withdrawal requiring immediate intervention. Other findings are common but less severe. ## 심화 해설 Core Nursing Explanation **Key Concept Analysis**: This question tests the ability to prioritize assessment findings in a patient experiencing Alcohol Withdrawal Syndrome (AWS). The core theme is recognizing the progression from minor withdrawal symptoms to life-threatening complications. AWS follows a predictable timeline: minor symptoms (anxiety, tremors) appear 6-12 hours after the last drink, can progress to Alcohol Withdrawal Seizures (12-48 hours), and culminate in Delirium Tremens (DTs) (48-96 hours). DTs are a medical emergency characterized by severe autonomic hyperactivity and global confusion. **Answer Rationale**: Key Point! Option ②, "Visual hallucinations with severe agitation and disorientation," is the hallmark of Delirium Tremens (DTs). This is the most serious complication because it carries a significant mortality risk if untreated. The combination of hallucinations (often visual, like insects), disorientation (to person, place, time), and severe agitation indicates profound central nervous system dysfunction and requires immediate pharmacological intervention (e.g., benzodiazepines like lorazepam) and close monitoring to prevent injury, seizures, or cardiovascular collapse. **Distractor Analysis**: Watch out for confusion! Option ①: While a BP of 150/90 mmHg and HR of 110 bpm indicate autonomic hyperactivity (common in withdrawal), these **vital sign abnormalities alone** are not diagnostic of the most serious stage. They are often present in moderate withdrawal and are managed with standard benzodiazepine protocols. Option ③: Nausea, vomiting, and anorexia are common early symptoms of AWS and gastrointestinal disturbances related to alcohol cessation. They are uncomfortable but not immediately life-threatening. Option ④: Mild tremors, anxiety, and restlessness are classic signs of minor alcohol withdrawal. They signal the need for assessment and likely initiation of a withdrawal protocol (like CIWA-Ar scale) but do not constitute an emergency like DTs. **Related Concepts**: The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale is the gold standard for assessing withdrawal severity and guiding treatment. Key items include agitation, anxiety, auditory/visual/tactile disturbances, headache, orientation, nausea/vomiting, paroxysmal sweats, tactile disturbances, tremor. A high score indicates severe withdrawal and the need for aggressive treatment. ## 임상 시나리오 Nursing Clinical Practice Guide **Clinical Scenario**: You are the nurse in the ED. A 45-year-old male is brought in by family. His last drink was about 60 hours ago. He is pacing, sweating profusely, and swatting at the air, yelling "Get them off me!" He does not know what day it is or why he is in the hospital. **Nursing Intervention Strategy**: 1. **Immediate Assessment & Safety**: Your first priority is safety. Approach calmly. Perform a rapid CIWA-Ar assessment. His visual hallucinations and disorientation score high. Immediately notify the physician/APRN. Ensure the environment is safe: lower the bed, pad side rails, remove potential hazards. A sitter may be required for constant observation. 2. **Pharmacological Management**: Expect an order for a benzodiazepine (e.g., IV lorazepam) per protocol. Administer promptly and monitor response (decreased agitation, vital signs). Dosing is often "front-loaded" until the patient is calm but arousable. 3. **Ongoing Monitoring**: Monitor vital signs and neurological status frequently (every 15-30 minutes initially). Watch for seizure activity. Assess for and treat co-morbidities like dehydration (IV fluids) and electrolyte imbalances (especially hypomagnesemia, hypokalemia). 4. **Supportive Care & Education**: Reorient the patient gently and frequently. Use simple, clear statements. After stabilization, initiate education about the dangers of AWS and resources for alcohol use disorder treatment. **Patient Safety and Precautions**: Never leave a patient with active DTs unattended. Use restraints only as a last resort and with a physician's order, following strict protocol, as physical struggle can increase metabolic demand and risk of injury. Be aware that benzodiazepines can cause respiratory depression, especially if combined with other CNS depressants—monitor respiratory rate and oxygen saturation closely. Nursing Procedure & Medication Flow **CIWA-Ar Assessment Flow**: Assess 10 items (0-7 scale each), total score guides intervention. >15-20 = Moderate-Severe withdrawal. **Benzodiazepine Administration**: First-line is lorazepam (Ativan) or diazepam (Valium). Lorazepam is preferred in liver dysfunction (not metabolized by liver). Administer IV push slowly. Have flumazenil (Romazicon) available as a reversal agent. A Word from Your Senior Nurse "In the chaos of the ED, the patient swatting at invisible bugs might seem dramatic, but to us, it's a huge red flag waving, screaming 'DELIRIUM TREMENS!' Recognizing this isn't just about passing a test—it's about saving a life. Your quick assessment and action to get that benzodiazepine on board can be the difference between a controlled medical situation and a full-blown crisis. Always connect the dots: timeline + symptoms = stage of withdrawal. This clinical reasoning is what makes you a nurse, not just a test-taker." ## 같은 주제 문제 - [A nurse is assessing a 28-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=319722) - [A nurse is assessing a 35-year-old client who was admitted to the emergency department fol…](https://mymerci.kr/pages/nclex_q.php?qn_id=319723) - [A nurse is assessing a 45-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=319724) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._