# A nurse is assessing a 45-year-old client admitted to the emergency department with suspected alcohol withdrawal. The client exhibits tremors, diaphoresis, and reports seeing insects crawling on the walls. Which assessment finding would be the most critical indicator requiring immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543410 > language: ko > subject: Mental Health ## 문제 A nurse is assessing a 45-year-old client admitted to the emergency department with suspected alcohol withdrawal. The client exhibits tremors, diaphoresis, and reports seeing insects crawling on the walls. Which assessment finding would be the most critical indicator requiring immediate intervention? ## 보기 1. Blood pressure 180/110 mmHg with heart rate 120 bpm **✔ 정답** 2. Mild hand tremors and complaints of nausea 3. Restlessness and difficulty concentrating 4. Reports of anxiety and sleep disturbances **정답: 1** ## 해설 Severe hypertension (180/110 mmHg) and tachycardia (120 bpm) indicate life-threatening alcohol withdrawal complications like delirium tremens, requiring immediate intervention. Other options represent milder withdrawal symptoms manageable with standard care. ## 심화 해설 Clinical Context: Alcohol Withdrawal Syndrome (AWS) The client's presentation—tremors, diaphoresis, and visual hallucinations (seeing insects)—indicates a progression from uncomplicated withdrawal to alcohol withdrawal syndrome with perceptual disturbances. This state reflects central nervous system hyperexcitability due to the abrupt removal of alcohol, which is a GABA receptor agonist and NMDA receptor antagonist [2]. The loss of this chronic CNS depression leads to a surge of excitatory neurotransmitters, clinically manifesting as autonomic hyperactivity and psychiatric symptoms. Critical Assessment Finding: Autonomic Instability The most critical indicator requiring immediate intervention is a blood pressure of 180/110 mmHg with a heart rate of 120 bpm. This finding represents severe autonomic hyperactivity, a hallmark of severe alcohol withdrawal that can herald life-threatening complications. While alcohol withdrawal symptoms exist on a spectrum from benign to severe [1], this degree of sympathetic surge indicates a high risk for progression to severe alcohol withdrawal syndrome (SAWS), which carries risks of cardiac arrhythmia, myocardial ischemia, and the development of delirium tremens [3]. The other options represent expected or less immediately dangerous symptoms. Mild tremors and nausea (Option 2) are common early withdrawal signs. Restlessness and difficulty concentrating (Option 3), along with anxiety and sleep disturbances (Option 4), are typical psychological manifestations. However, they do not pose the same imminent physiological threat as uncontrolled hypertension and tachycardia. In the context of SAWS, particularly in patients who may have underlying alcohol-associated liver disease (ALD), standard treatments like benzodiazepines can be complicated by altered drug metabolism and increased toxicity, including over-sedation and respiratory depression [3]. This makes the prompt recognition and management of severe autonomic instability a nursing priority to prevent decompensation. Validated clinical withdrawal scoring tools, such as the modified Minnesota Detoxification Scale (mMINDS), are recommended by guidelines to objectively score a patient's withdrawal severity and guide treatment decisions . A finding of severe hypertension and tachycardia would significantly elevate such a score, signaling the need for immediate pharmacological intervention to stabilize the patient and prevent progression to more severe sequelae. References (research sources) - [1]Alcohol Withdrawal.Research articleMeloy P, Rutz D, Bhambri A. (2025) · DOI: 10.21980/j87s8q - [2]Dexmedetomidine for Alcohol Withdrawal: Looks Can Be Deceiving.Research articleRiggan M, Schmitz Z, Hoffman RS, Biary N, Biary R. (2025) · DOI: 10.7759/cureus.95851 - [3]Safety and effectiveness of phenobarbital vs. benzodiazepines for severe alcohol withdrawal in alcohol-associated liver disease in the ICU.Research articleGovalan R, Hao S, Kenes MT, McSparron JI, Tapper EB. (2026) · DOI: 10.1016/j.jhepr.2026.101769 ## 임상 시나리오 Clinical Guide: Severe Alcohol WithdrawalRecognizing and Prioritizing Autonomic Instability A blood pressure of 180/110 mmHg with a heart rate of 120 bpm indicates severe autonomic hyperactivity, the most critical finding in alcohol withdrawal. This sympathetic surge signals a high risk for progression to delirium tremens and cardiovascular collapse. Use a validated tool like the CIWA-Ar to score symptom severity. A score over 15 generally indicates a need for pharmacological intervention, but severe vital sign changes alone warrant immediate action regardless of total score. CautionDo not dismiss isolated vital sign abnormalities. Uncontrolled hypertension and tachycardia can precipitate myocardial ischemia or cardiac arrhythmia. Benzodiazepines are first-line to stabilize autonomic function and prevent seizure activity. ## 핵심 개념 - **Alcohol Withdrawal Syndrome (AWS)** — A spectrum of symptoms that occur after abrupt cessation of chronic alcohol intake, ranging from mild anxiety to severe autonomic hyperactivity and delirium tremens. - **Autonomic Hyperactivity** — Excessive activity of the sympathetic nervous system, manifesting as hypertension, tachycardia, diaphoresis, and tremors, commonly seen in severe alcohol withdrawal. - **Delirium Tremens (DTs)** — The most severe form of alcohol withdrawal, characterized by profound confusion, severe autonomic instability, and hallucinations, with a significant mortality risk if untreated. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=543409) - [A nurse is assessing a 35-year-old client who was admitted to the emergency department fol…](https://mymerci.kr/pages/nclex_q.php?qn_id=543411) - [A nurse is assessing a 28-year-old client admitted to the emergency department with suspec…](https://mymerci.kr/pages/nclex_q.php?qn_id=543412) - [A nurse is caring for a client with alcohol use disorder who is experiencing withdrawal sy…](https://mymerci.kr/pages/nclex_q.php?qn_id=543413) - [A nurse is assessing a client with alcohol withdrawal in the emergency department. 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