# A nurse is caring for a client with alcohol use disorder who is experiencing withdrawal symptoms. Which nursing intervention should be the priority?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543419  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a client with alcohol use disorder who is experiencing withdrawal symptoms. Which nursing intervention should be the priority?

## 보기

1. Monitor vital signs and neurological status frequently **✔ 정답**
2. Encourage the client to discuss feelings about alcohol use
3. Provide educational materials about alcoholism
4. Schedule group therapy sessions immediately

**정답: 1**

## 해설

Monitoring vital signs and neurological status is the priority for alcohol withdrawal due to risk of life-threatening complications like delirium tremens. Psychosocial interventions are important but secondary during acute withdrawal.

## 심화 해설

Understanding the Priority in Alcohol Withdrawal Syndrome

When a client with alcohol use disorder is experiencing withdrawal, the immediate physiological threat is the development of Alcohol Withdrawal Syndrome (AWS). This is not merely discomfort; it is a potentially life-threatening condition that can rapidly progress to severe autonomic instability, hallucinations, and seizures. The foundational principle in managing AWS, as highlighted in clinical guidelines, is that "abrupt changes in alcohol or other drug use is associated with the risk of experiencing a withdrawal syndrome" [1]. Therefore, the nurse's priority is to ensure physiological safety through continuous assessment.

Why Frequent Monitoring is the Priority

The correct intervention, monitoring vital signs and neurological status frequently, directly addresses the pathophysiology of AWS. Chronic alcohol use depresses the central nervous system by potentiating the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and inhibiting the excitatory neurotransmitter glutamate. When alcohol is abruptly removed, the brain enters a hyper-excitable state due to a sudden drop in GABA activity and a surge in glutamate. This neurochemical imbalance manifests as the symptoms of withdrawal.

Frequent monitoring using a standardized tool like the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) is essential. This scale quantifies the severity of withdrawal by scoring key indicators that a nurse must assess:

- Vital Signs: Tachycardia (pulse >100 bpm) and hypertension (systolic BP >150 mm Hg) are cardinal signs of autonomic hyperactivity.

- Neurological Status: The nurse must watch for tremor, agitation, anxiety, and, critically, signs of severe withdrawal like hallucinations or clouding of sensorium, which indicate progression to delirium tremens (DTs). DTs is a medical emergency with a mortality rate of up to 5% if untreated, characterized by profound confusion, severe autonomic instability, and seizures.

A retrospective cohort study analyzing AWS management confirms that the focus of care is on "symptom severity, treatment protocols, and factors associated with prolonged or complicated hospital stays" [2]. The primary determinant for administering rescue medication, typically benzodiazepines, is the CIWA-Ar score, which is entirely dependent on the nurse's frequent and accurate assessments. Delaying this assessment to focus on psychosocial interventions first could allow the client to deteriorate into a seizure or DTs without timely pharmacological intervention.

Analyzing the Other Options

- Option 2: Encourage the client to discuss feelings about alcohol use. While therapeutic communication is a vital nursing role, a client in acute withdrawal is in a state of physiological crisis. The severe anxiety, agitation, and potential cognitive impairment make meaningful discussion about feelings nearly impossible and therapeutically ineffective. This intervention is appropriate once the client is medically stable and no longer in acute distress.

- Option 3: Provide educational materials about alcoholism. Education is a crucial component of long-term recovery and relapse prevention. Initiatives to improve care for alcohol use disorder include "structured screening during the secondary nursing assessment, brief intervention..." . However, a client in acute withdrawal is not in a learning-ready state. Their ability to concentrate and process new information is significantly compromised by the neurochemical storm they are experiencing. This intervention is a lower priority than physiological stabilization.

- Option 4: Schedule group therapy sessions immediately. Group therapy is a psychosocial intervention for the rehabilitation phase of treatment. An integrated approach to recovery may eventually involve "multidisciplinary relaxing techniques" as an adjunct to medical management , but this is never the priority during the acute withdrawal phase. Placing a client in a group setting while they are acutely agitated, tachycardic, and at risk for seizure is not only therapeutically inappropriate but also unsafe for both the client and others. The immediate need is medical management and intensive nursing surveillance to prevent life-threatening complications.

The nurse's primary responsibility is to first address the physiological instability of the acute withdrawal phase through vigilant monitoring, which guides life-saving pharmacotherapy and prevents progression to severe complications like seizures and delirium tremens.References (research sources)

- [1]The Management of Withdrawal From Alcohol and Other Drugs in Australian Custodial Settings: A Consensus Statement.GuidelineFitzGerald G, Chan J, Cook J, Stoove M, Curtis M, Nielsen S, Winter RJ, Naren T. (2026) · DOI: 10.5694/mja2.70225

- [2]Clinical characteristics and outcomes of adult patients admitted to acute care settings for alcohol withdrawal syndrome.Research articleSalehi A, Barman M, Illahi MN, Alhariri BNA, Nashwan AJ, Singh K. (2026) · DOI: 10.5339/qmj.2026.6

## 임상 시나리오

Managing Acute Alcohol WithdrawalPrioritizing Physiological Safety with CIWA-Ar
The immediate priority in alcohol withdrawal is continuous physiological monitoring to prevent progression to seizures or delirium tremens. Use the CIWA-Ar scale to score symptoms like nausea, tremor, agitation, and headache.

Assess vital signs and neurological status every 1 to 4 hours depending on the score. Pharmacological intervention with benzodiazepines is typically triggered by a CIWA-Ar score above 8 to 10 to stabilize CNS hyper-excitability.

CautionDo not delay assessment to focus on psychosocial or educational interventions. Autonomic instability (tachycardia, hypertension) can rapidly escalate to life-threatening seizures, making physiological safety the absolute priority.

## 핵심 개념

- **Alcohol Withdrawal Syndrome (AWS)** — A potentially life-threatening condition resulting from abrupt cessation of alcohol intake, characterized by CNS hyper-excitability due to GABA downregulation and glutamate upregulation.
- **CIWA-Ar** — Clinical Institute Withdrawal Assessment for Alcohol, Revised; a standardized 10-item scale used to quantify the severity of alcohol withdrawal symptoms and guide pharmacological management.
- **GABA** — Gamma-aminobutyric acid, the primary inhibitory neurotransmitter in the brain, which is potentiated by chronic alcohol use and downregulated during withdrawal.
- **Glutamate** — The primary excitatory neurotransmitter in the brain, which is inhibited by chronic alcohol use and surges during withdrawal, leading to neuro-excitation.
- **Priority Setting** — A nursing process component based on Maslow's hierarchy or the ABCs (Airway, Breathing, Circulation); physiological safety always takes precedence over psychosocial or educational needs.

## 같은 주제 문제

- [A nurse is assessing a 38-year-old client who was admitted to the emergency department fol…](https://mymerci.kr/pages/nclex_q.php?qn_id=543416)
- [A nurse is assessing a client who has been admitted for alcohol withdrawal. Which assessme…](https://mymerci.kr/pages/nclex_q.php?qn_id=543417)
- [A nurse is caring for a client with alcohol use disorder who is experiencing severe withdr…](https://mymerci.kr/pages/nclex_q.php?qn_id=543418)
- [A nurse is caring for a client with chronic alcohol use disorder who was admitted 48 hours…](https://mymerci.kr/pages/nclex_q.php?qn_id=543420)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._