# Stage 4 — Generate solutions. Alcohol withdrawal delirium is the leading diagnosis, and postoperative alternatives remain under evaluation. Which interventions are appropriate now? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372480&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

Stage 4 — Generate solutions. Alcohol withdrawal delirium is the leading diagnosis, and postoperative alternatives remain under evaluation. Which interventions are appropriate now? Select all that apply.

1

Provide continuous one-to-one observation with frequent vital signs, oximetry, cardiac monitoring, IV access, and resuscitative equipment available

2

Administer protocol-guided IV benzodiazepine in individualized doses toward light somnolence while monitoring sedation and respiratory status

3

Continue CIWA-Ar self-report scoring during delirium and use the resulting number to confirm the diagnosis and exclude postoperative causes

4

Give parenteral thiamine, provide glucose when clinically indicated without delaying either treatment, and replace the documented low magnesium

5

Use a quiet well-lit environment, maintain fall and seizure safety measures, and continue evaluation for infection, hypoxia, medication effects, and metabolic causes

6

Use an antipsychotic as the only withdrawal medication and apply physical restraints routinely before assessing less restrictive safety measures

## Explanation

Four appropriate interventions
Correct care combines one-to-one monitored care; individualized IV benzodiazepine treatment; parenteral thiamine with indicated glucose and magnesium replacement; and environmental safety plus continued differential evaluation. CIWA-Ar is not appropriate for ongoing monitoring during delirium, antipsychotics are not monotherapy for withdrawal delirium, and restraints are reserved for injury prevention when required.

## In-depth explanation

Step 1 — Intensify observation and monitoring
Alcohol withdrawal delirium often requires intensive or critical care. A disoriented, agitated client needs continuous observation, frequent vital signs, oximetry and cardiac monitoring, IV access, and ready resuscitative equipment.

Step 2 — Treat with benzodiazepine
Benzodiazepines are first line. Doses are individualized under an established protocol to achieve light somnolence, with close monitoring for oversedation and respiratory depression.

Step 3 — Correct the supportive-care myths
Give parenteral thiamine in severe withdrawal. ASAM states that thiamine and glucose may be given in either order or concurrently, so urgent glucose is not delayed. Replace magnesium here because a low value is documented, not as universal withdrawal prophylaxis.

Step 4 — Keep safety and differential work active
Use a quiet, well-lit environment and direct observation. Antipsychotics may be adjunctive for hallucinations not controlled by benzodiazepines but are not monotherapy. Restraints are used only when required to prevent injury and according to law and policy.

NCLEX rule
Choose simultaneous definitive treatment, monitoring, supportive care, and reassessment for mimics.

## Clinical scenario

Scenario (Stage 4 — Generate solutions)
The rapid-response team is evaluating a postoperative client with probable alcohol withdrawal delirium.

Clinical judgment target
Select a monitored treatment bundle and reject invalid assessment or unsafe monotherapy.

## Key concepts

- **Protocol-guided benzodiazepine** — An individualized regimen using an established hospital protocol, clinical signs, and ongoing sedation and respiratory assessment.
- **Parenteral thiamine** — IV or IM vitamin B1 used to prevent or treat neurologic injury in patients at risk; urgent glucose need not wait for it.
- **Adjunctive antipsychotic** — A possible addition for hallucinations not controlled by benzodiazepines; it does not replace first-line withdrawal-delirium treatment.

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