# The nurse reviews the admission record for a client who stopped drinking alcohol. Which findings require immediate follow-up for severe or complicated withdrawal? Highlight the high-risk findings. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568936&lang=en > language: en > subject: Mental Health Concepts > category: PSI ## Question The nurse reviews the admission record for a client who stopped drinking alcohol. Which findings require immediate follow-up for severe or complicated withdrawal? Highlight the high-risk findings. Nurses' Notes 0700: The client reports the last alcohol use occurred about 36 hours ago. The admission history states that the client slept poorly and woke several times overnight. The client is anxious but answers questions appropriately. A prior record shows a generalized seizure during alcohol withdrawal two years ago. At 0730, the client eats half of breakfast without vomiting. The client follows one-step directions and accepts oral fluids. At 0830, the client remains oriented to person, place, date, and situation. The nurse administers medication according to the withdrawal protocol. At 0930, pulse is 126/min with heavy sweating despite treatment, and blood pressure is 174/102 mm Hg. The client reports mild sensitivity to hallway noise. At 1000, the client walks with assistance and follows safety instructions. The nurse documents that the resting pulse was 82/min during the initial assessment. At 1130, the client develops new disorientation and reports seeing insects on the wall. The client states that appetite is better than it was yesterday. Seizure precautions and close observation are continued. ## Explanation Follow up on a prior withdrawal seizure, marked autonomic hyperactivity despite treatment, and new disorientation with visual hallucinations. These findings increase concern for seizure or alcohol withdrawal delirium. ## In-depth explanation Quick answer The high-risk findings are a previous withdrawal seizure, persistent marked autonomic hyperactivity despite treatment, and new disorientation with visual hallucinations. These cues require rapid reassessment and escalation for complicated withdrawal. Why this is correct Alcohol withdrawal can progress quickly to seizures or delirium. A history of withdrawal seizure or delirium raises future risk, while tachycardia, hypertension, sweating, agitation, disorientation, and hallucinations can signal severe progression. Timing guides vigilance, but clients do not always move through stages in a fixed sequence.[2] Easy analogy or mental picture Think of withdrawal as an electrical system losing its brake. A prior seizure shows the system has overloaded before, autonomic surges show rising current, and delirium shows the whole control panel is failing. The picture does not replace structured assessment or medication monitoring. Memory hook Past seizure, rising autonomic storm, changing reality: escalate before the circuit overloads. NCLEX decision rule For alcohol withdrawal, assess both current severity and predictors of future complications. Prior complicated withdrawal plus worsening autonomic or mental-status findings outranks mild insomnia, appetite changes, or anxiety that remains responsive to care. Why the other choices are wrong Mild insomnia, cooperative behavior, improving appetite, orientation, and a stable pulse do not show the same complicated pattern. They still require scheduled assessment because withdrawal can change, but they are not the high-risk cues selected here.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]ASAM: Alcohol Withdrawal Management GuidelineAmerican Society of Addiction Medicine ## Related questions - [A client hospitalized for depression says, "My family would be better off without me." Whi…](https://mymerci.kr/pages/nclex_q.php?qn_id=393687&lang=en) - [A client with schizophrenia says, "The voices are telling me to do something bad." Which r…](https://mymerci.kr/pages/nclex_q.php?qn_id=394025&lang=en) - [A client arrives with bruises at different stages of healing. 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