# A 60-year-old client with chronic alcohol use disorder is admitted to the emergency department 36 hours after the last drink. The client has coarse tremors, profuse diaphoresis, and visual hallucinations. Vital signs are BP 170/100 mm Hg, HR 122/min, and temperature 38.0°C (100.4°F); the CIWA-Ar score is 22. Which immediate priority interventions should the nurse implement? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368099&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A 60-year-old client with chronic alcohol use disorder is admitted to the emergency department 36 hours after the last drink. The client has coarse tremors, profuse diaphoresis, and visual hallucinations. Vital signs are BP 170/100 mm Hg, HR 122/min, and temperature 38.0°C (100.4°F); the CIWA-Ar score is 22. Which immediate priority interventions should the nurse implement? Select all that apply.

1

Implement seizure precautions, including a low bed, padded side rails, suction available, and close observation

2

Place the client alone in a dimly lit room and avoid frequent reorientation so stimulation is minimized

3

Give prescribed parenteral thiamine promptly without delaying glucose needed for hypoglycemia

4

Reassess the CIWA-Ar score and vital signs every 1 to 2 hours while the client can answer reliably

5

Give prescribed IV lorazepam promptly to treat withdrawal and reduce seizure and withdrawal-delirium risk

6

Maintain close observation and assess suicide and self-harm risk when the client's condition permits

## Explanation

This client has severe alcohol withdrawal with marked autonomic hyperactivity and hallucinations. Administer the prescribed benzodiazepine promptly because benzodiazepines are first-line treatment and reduce seizure and withdrawal-delirium risk (Choice 5). Give parenteral thiamine promptly, but do not delay urgently needed glucose for hypoglycemia; thiamine and glucose may be given in either order or concurrently (Choice 3). Use frequent vital-sign and symptom reassessment to guide protocol-based dosing while the client can participate reliably; use an objective delirium scale if delirium prevents reliable CIWA-Ar responses (Choice 4). Institute seizure precautions and close observation (Choice 1). Assess suicide and self-harm risk as soon as the client's condition permits because hallucinations, mood symptoms, and impaired judgment can increase immediate safety risk (Choice 6). A calm, low-stimulation environment is appropriate, but the room should be adequately lit and the client should receive frequent orientation; isolation in dim lighting can worsen misperceptions (Choice 2).

## In-depth explanation

Alcohol Withdrawal Timeline
1. Mild (6-12 hr): tremor, anxiety, headache, insomnia — CIWA-Ar 0-9
2. Hallucinations (12-24 hr): visual/tactile/auditory; sensorium clear
3. Withdrawal seizures (24-48 hr): grand mal, 3-5%
4. DT (48-96 hr): autonomic hyperactivity + altered consciousness + hallucinations — mortality 5-15%

CIWA-Ar Driven Therapy
0-9 mild: monitor
10-14 moderate: PRN BZD
15-19 severe: scheduled BZD
20+ very severe: high-dose BZD + 1:1, consider ICU

Thiamine Before Glucose
Thiamine 100 mg IV before dextrose in malnourished AUD — glucose can deplete remaining thiamine and precipitate Wernicke-Korsakoff.

Memory Tip
"BZD before brain damage; Thiamine before sugar"

## Clinical scenario

Scenario
60 yo, chronic AUD, last drink 36 hr ago, in ED. Coarse tremor, diaphoresis, visual hallucinations, HR 122, BP 170/100, T 38.0°C, CIWA-Ar 22. Severe withdrawal — DT imminent.

Priority Actions
1. ABC stabilization
2. Lorazepam IV — first-line
3. Thiamine 100 mg IV then D5NS
4. CIWA-Ar q1-2h with symptom-triggered titration
5. Seizure + suicide precautions

Avoid
- Dim lighting (worsens hallucinations)
- Glucose alone (precipitates Wernicke)
- Unmodified environment
- Skipping suicide assessment

## Key concepts

- **CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised)** — A validated 10-item tool (0-67 points) assessing nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, and orientation. Score at or above 15 indicates severe withdrawal requiring scheduled BZDs and intensive monitoring; at or above 20 may warrant ICU.
- **Delirium Tremens (DT)** — A severe alcohol withdrawal syndrome appearing 48-96 hours after the last drink. Features autonomic hyperactivity (tachycardia, hypertension, hyperthermia, diaphoresis), altered mental status, hallucinations, agitation, and tremor. Mortality 5-15% if untreated; requires ICU-level monitoring, high-dose benzodiazepines, and 1:1 observation.
- **Wernicke Encephalopathy** — Acute thiamine (vitamin B1) deficiency syndrome. Classic triad: ophthalmoplegia, ataxia, and confusion. Common in malnourished alcohol-dependent clients; glucose administration can deplete remaining thiamine and precipitate the syndrome — therefore thiamine 100 mg IV/IM must precede any dextrose-containing fluid. Untreated, progresses to Korsakoff syndrome (permanent short-term memory loss).

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