# A client is on postoperative day 3 after internal fixation of a hip fracture. The admission history documents daily heavy alcohol use, with the last drink about 60 hours ago. At 0800 the CIWA-Ar score was 6. At 1400 the client is picking at the sheets, says there are insects on the blanket, and is oriented to person only. CIWA-Ar score 19, HR 124/min, BP 164/98 mm Hg, T 38.1 C, RR 22/min, SpO2 96% on room air, coarse tremor, and diaphoresis. The symptom-triggered protocol orders lorazepam 2 mg IV for a CIWA-Ar score of 10 or higher. Which actions should the nurse take? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617267&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

A client is on postoperative day 3 after internal fixation of a hip fracture. The admission history documents daily heavy alcohol use, with the last drink about 60 hours ago. At 0800 the CIWA-Ar score was 6. At 1400 the client is picking at the sheets, says there are insects on the blanket, and is oriented to person only. CIWA-Ar score 19, HR 124/min, BP 164/98 mm Hg, T 38.1 C, RR 22/min, SpO2 96% on room air, coarse tremor, and diaphoresis. The symptom-triggered protocol orders lorazepam 2 mg IV for a CIWA-Ar score of 10 or higher. Which actions should the nurse take? Select all that apply.

1

Notify the provider of the new disorientation and temperature

2

Turn off the room lights and close the door to limit stimulation

3

Request an order for IV haloperidol to control the hallucinations

4

Apply bilateral soft wrist restraints to protect the surgical hip

5

Administer lorazepam 2 mg IV per the symptom-triggered protocol

6

Repeat the CIWA-Ar assessment 1 hour after the lorazepam dose

## Explanation

The score rise from 6 to 19 at about 60 hours after the last drink, with disorientation, fever, and autonomic hyperactivity, fits the 48-96 hour window for withdrawal delirium, so the protocol dose is given, the response is rechecked in 1 hour, and the provider is notified of the new delirium and fever. Haloperidol is tempting because the client is hallucinating, but it does not treat withdrawal and lowers the seizure threshold, so it is only an adjunct after adequate benzodiazepine. Restraints and a dark room are tempting safety and calming measures but increase agitation and misperception.

## In-depth explanation

Quick answer
Give the protocol lorazepam, recheck CIWA-Ar in 1 hour, and notify the provider (options 5, 6, 1).

Why this is correct
Timing is the key cue: the last drink was about 60 hours ago, inside the 48-96 hour window when withdrawal delirium appears. The score jumped from 6 to 19, so the protocol threshold of 10 is met and lorazepam is indicated now. Symptom-triggered protocols require reassessment after each dose to decide on repeat dosing. New disorientation plus a temperature of 38.1 C is a change in mental status that the provider must evaluate (delirium tremens, and infection in a postoperative client, both need workup).

Easy analogy or mental picture
Withdrawal is like a car whose brake (alcohol) was suddenly removed: the benzodiazepine is the replacement brake, and haloperidol only covers the windshield so you cannot see how fast you are going.

Memory hook
Day 2 to 4 after the last drink = watch for DTs: dose, recheck, report.

NCLEX decision rule
When a protocol threshold is met, act on the protocol first, reassess on its schedule, and escalate any new change in orientation or fever.

Why the other choices are wrong
Haloperidol (option 3) is tempting because hallucinations look like psychosis, but antipsychotics do not treat the GABA deficit and lower the seizure threshold; they are adjuncts only after adequate benzodiazepine. Restraints (option 4) seem to protect the hip, but in delirium they increase agitation, injury, and aspiration risk and are a last resort after sedation and close observation. A dark, closed room (option 2) sounds like low stimulation, but darkness increases visual misperceptions; a quiet, well-lit room with frequent observation is preferred.

References
1StatPearls: Alcohol WithdrawalTiming of withdrawal delirium and benzodiazepines as first-line treatment
2ASAM Clinical Practice Guideline on Alcohol Withdrawal ManagementSymptom-triggered dosing, reassessment, and antipsychotics only as adjuncts

## Clinical scenario

Scenario
A postoperative client with heavy daily alcohol use moves from a CIWA-Ar of 6 to 19 about 60 hours after the last drink, with hallucinations, disorientation, fever, and autonomic hyperactivity.

## Key concepts

- **CIWA-Ar** — A 10-item scale that scores alcohol withdrawal severity and guides symptom-triggered benzodiazepine dosing.
- **Delirium tremens** — Severe alcohol withdrawal with disturbed consciousness, hallucinations, and autonomic hyperactivity, typically 48 to 96 hours after the last drink.
- **Symptom-triggered therapy** — Giving benzodiazepine doses only when a validated score meets a set threshold, with reassessment after each dose.

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