# A client admitted 18 hours after the last alcohol drink has tremor, diaphoresis, BP 168/96, HR 116, and visual hallucinations. Which interventions should the nurse anticipate? Select all that apply.

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> language: en  
> subject: Safety and Infection Prevention and Control  
> category: SIPC

## Question

A client admitted 18 hours after the last alcohol drink has tremor, diaphoresis, BP 168/96, HR 116, and visual hallucinations. Which interventions should the nurse anticipate? Select all that apply.

1

Restrict the client from any 12-step or peer support contact during withdrawal

2

Give IV thiamine 100 mg before any IV dextrose-containing fluid

3

Administer benzodiazepine using a symptom-triggered (CIWA-Ar based) protocol

4

Use frequent reorientation and a calm low-stimulation environment

5

Implement seizure and fall precautions

## Explanation

Symptom-triggered benzodiazepine dosing per CIWA-Ar reduces total benzodiazepine exposure and length of stay compared with fixed schedules. Thiamine 100 mg IV is given BEFORE glucose to prevent Wernicke encephalopathy. Seizure and fall precautions cover withdrawal seizure risk peaking 24-48 hours. Frequent reorientation and low stimulation prevent escalation. Cutting peer/12-step support is harmful — recovery support improves engagement and outcomes.

## In-depth explanation

CIWA-Ar score: under 8 minimal, 8-15 mild, 16-20 moderate, over 20 severe. Delirium tremens peaks 48-96 hours; mortality up to 5 percent untreated.

## Clinical scenario

CIWA-Ar score 22. History of alcohol use disorder, daily drinking 12 years. No prior seizures.

## Key concepts

- **CIWA-Ar** — Clinical Institute Withdrawal Assessment for Alcohol revised; 10-item severity scale.
- **delirium tremens** — Severe alcohol withdrawal with confusion, autonomic instability, hallucinations.
- **Wernicke encephalopathy** — Thiamine deficiency causing ophthalmoplegia, ataxia, confusion; precipitated by glucose without thiamine.

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