# Stage 2 — Analyze cues. Complete the statements about timing, assessment-tool selection, and interpretation for a client who is now delirious.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372478&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

Stage 2 — Analyze cues. Complete the statements about timing, assessment-tool selection, and interpretation for a client who is now delirious.

Alcohol withdrawal delirium can develop as late as ::선택::less than 13 to 514 to 21 days after cessation. Because this client cannot reliably self-report, the nurse should stop using ::선택::CIWA-Arcontinuous oximetrycardiac monitoring for ongoing delirium monitoring and use an objective tool such as ::선택::RASS or MINDSAUDIT-CBraden Scale. The selected scale should ::선택::guide treatment and reassessmentconfirm the cause of deliriumexclude postoperative complications rather than establish the diagnosis by itself.

## Explanation

Four analysis rules
Alcohol withdrawal delirium can emerge as late as 3 to 5 days after cessation. Once delirium prevents reliable self-report, do not continue CIWA-Ar for ongoing monitoring; use an objective scale such as RASS or MINDS. A severity score helps guide and reassess protocol treatment but does not establish the diagnosis.

## In-depth explanation

Step 1 — Use timing correctly
The client at 72 hours remains within the described window for alcohol withdrawal delirium. Timing raises or lowers probability but cannot exclude other postoperative causes.

Step 2 — Match the scale to the client
CIWA-Ar includes patient-reported symptoms and is not recommended by ASAM for a client with delirium who cannot answer reliably. RASS, MINDS, CAM-ICU, or another institution-approved objective tool is more appropriate.

Step 3 — Separate measurement from diagnosis
Withdrawal scales quantify signs or guide treatment; they are not diagnostic tests. Diagnosis requires the history, syndrome, examination, and evaluation for mimics.

NCLEX rule
A tool is valid only when its required inputs fit the client’s current condition.

## Clinical scenario

Scenario (Stage 2 — Analyze cues)
The client can no longer provide reliable symptom reports because attention and orientation fluctuate.

Clinical judgment target
Choose an appropriate monitoring tool and avoid turning a score into a diagnosis.

## Key concepts

- **CIWA-Ar limitation** — CIWA-Ar depends partly on self-report and is not recommended for monitoring alcohol withdrawal delirium.
- **RASS** — The Richmond Agitation-Sedation Scale objectively describes agitation and sedation and can be used during delirium care.
- **MINDS** — The Minnesota Detoxification Scale is an objective structured option used by some institutions for severe withdrawal or delirium monitoring.

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