# A nurse is caring for a client experiencing alcohol withdrawal. Which nursing intervention should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543425 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a client experiencing alcohol withdrawal. Which nursing intervention should be the highest priority? ## 보기 1. Encourage the client to participate in group therapy sessions 2. Provide nutritional supplements and a high-protein diet 3. Monitor for signs of delirium tremens and seizure activity **✔ 정답** 4. Administer prescribed antiemetic medications for nausea **정답: 3** ## 해설 Monitoring for delirium tremens and seizure activity is the highest priority because these are life-threatening complications requiring immediate intervention. Other interventions like group therapy, nutrition, and antiemetics are important but secondary to safety monitoring. ## 심화 해설 Understanding Alcohol Withdrawal and Priority Setting When caring for a client experiencing alcohol withdrawal, the nurse must apply a physiological safety framework rooted in the ABCs (Airway, Breathing, Circulation) and the prevention of life-threatening neurological events. Alcohol withdrawal syndrome results from the abrupt cessation or reduction of alcohol intake in a person with physical dependence. Chronic alcohol consumption enhances the inhibitory effects of gamma-aminobutyric acid (GABA) and suppresses the excitatory neurotransmitter glutamate. When alcohol is removed, the central nervous system (CNS) experiences a state of hyper-excitation because the sedative GABA effects are lost while glutamate activity surges unchecked . This neurochemical imbalance is the direct cause of withdrawal symptoms, which range from mild anxiety and tremors to severe complications. The highest priority intervention is to monitor for signs of delirium tremens and seizure activity. Delirium tremens (DTs) and withdrawal seizures represent the most severe, potentially fatal manifestations of alcohol withdrawal. DTs, characterized by profound confusion, autonomic hyperactivity (tachycardia, hypertension, hyperthermia), and hallucinations, carry a mortality rate of up to 5% even with treatment, often due to cardiac arrhythmia or respiratory failure [3]. Withdrawal seizures are typically generalized tonic-clonic and can occur within 12 to 48 hours after the last drink, but the timeline can be accelerated in older adults or those with medical comorbidities [3]. A consensus guideline emphasizes that the primary clinical objective during withdrawal management is to prevent and promptly treat these life-threatening neurological and autonomic complications [1]. Therefore, vigilant neurological and vital sign monitoring is a non-delegable, immediate safety action that directly protects airway integrity and cerebral function. Why the Other Options Are Lower Priority - Encouraging group therapy addresses psychosocial needs, which are important for long-term recovery from alcohol use disorder. However, a client in acute withdrawal is physiologically unstable, agitated, and cognitively impaired, making meaningful participation impossible and potentially dangerous if a medical emergency were to arise during the session. Psychosocial interventions are secondary to physiological stabilization . - Providing nutritional supplements targets common deficiencies like thiamine (to prevent Wernicke's encephalopathy) and electrolyte imbalances. While essential for comprehensive care, nutritional correction is a supportive measure that does not immediately prevent death from an active seizure or DTs. It is a priority, but not the highest priority in the acute phase of symptom escalation. - Administering antiemetics is a comfort-focused intervention for nausea, a common but non-lethal symptom. Treating nausea does not address the underlying CNS hyper-excitation that can rapidly progress to seizure or DTs. Symptom management must never take precedence over monitoring for and preventing life-threatening progression. The clinical approach is structured around a symptom-triggered assessment using a validated tool like the Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar). Frequent monitoring allows the nurse to detect escalating scores that herald severe withdrawal, triggering pharmacological intervention—typically with benzodiazepines—to stabilize the CNS and prevent progression to DTs and seizures . This proactive surveillance is the cornerstone of safe withdrawal management, as early recognition and treatment of autonomic instability and neurological irritability directly reduce mortality and morbidity [1][3].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 - [3]Delirium Tremens in the Older Adult.Research articleMulkey MA, Olson DM. (2020) · DOI: 10.1097/jnn.0000000000000543 ## 임상 시나리오 Alcohol Withdrawal: Priority AssessmentPreventing Life-Threatening Neurological Events The nurse's highest priority is to monitor for delirium tremens (DTs) and seizure activity. These are the most severe, potentially fatal complications of alcohol withdrawal, driven by CNS hyper-excitation when the inhibitory effects of alcohol are removed. Implement the CIWA-Ar protocol to assess withdrawal severity at regular intervals. Be aware that withdrawal seizures are typically generalized tonic-clonic and can occur within 12 to 48 hours after the last drink. DTs may peak later, often at 48 to 72 hours. CautionDelirium tremens carries a mortality rate of up to 5% even with treatment, often due to cardiac arrhythmia or respiratory failure. Seizure and fall precautions must be initiated immediately for any patient in active withdrawal. ## 핵심 개념 - **Delirium Tremens (DTs)** — Severe alcohol withdrawal syndrome characterized by confusion, autonomic hyperactivity (tachycardia, hypertension, hyperthermia), and hallucinations, with a mortality rate up to 5% even with treatment. - **Alcohol Withdrawal Seizures** — Generalized tonic-clonic seizures occurring 12-48 hours after last drink due to CNS hyper-excitation from loss of GABA effects and unopposed glutamate activity. - **GABA (Gamma-Aminobutyric Acid)** — Primary inhibitory neurotransmitter in the CNS; chronic alcohol use enhances its effects, and abrupt cessation leads to a loss of this inhibition, causing hyper-excitation. - **ABCs (Airway, Breathing, Circulation)** — A priority-setting framework in nursing that prioritizes physiological safety needs, with immediate threats to airway, breathing, or circulation taking precedence. - **Autonomic Hyperactivity** — A state of increased sympathetic nervous system activity seen in DTs, manifesting as tachycardia, hypertension, diaphoresis, and hyperthermia. ## 같은 주제 문제 - [A nurse is assessing a patient who was admitted 48 hours ago for alcohol detoxification. 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