# A client admitted for alcohol withdrawal is tremulous, diaphoretic, and reports seeing insects on the wall. Which nursing action is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396621&lang=en  
> language: en  
> subject: Family Dynamics  
> category: PSI

## Question

A client admitted for alcohol withdrawal is tremulous, diaphoretic, and reports seeing insects on the wall. Which nursing action is most appropriate?

## Option

1. Encourage the client to ambulate alone to reduce anxiety.
2. Implement seizure precautions and administer prescribed benzodiazepine therapy. **✔ Correct answer**
3. Turn off all lights and leave the client alone to sleep.
4. Offer caffeinated beverages to increase alertness.

**Correct answer: 2**

## Explanation

Severe alcohol withdrawal can cause hallucinations, autonomic instability, and seizures. Seizure precautions and prescribed benzodiazepine therapy are appropriate safety-focused interventions. Leaving the client alone or stimulating with caffeine increases risk.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Severe alcohol withdrawal.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Severe alcohol withdrawal, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Alcohol Withdrawal** — A syndrome after reduced alcohol intake that can include tremor, agitation, hallucinations, and seizures.
- **Seizure Precautions** — Safety measures to reduce injury if a seizure occurs.
- **Benzodiazepine** — A medication class commonly used to manage withdrawal symptoms and seizure risk.

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