# Stage 1 — Recognize cues. The nurse assesses a client on the orthopedic unit during the evening shift. Review the assessment note. Highlight the findings that require immediate follow-up.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617308&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

Stage 1 — Recognize cues. The nurse assesses a client on the orthopedic unit during the evening shift. Review the assessment note. Highlight the findings that require immediate follow-up.

A 58-year-old client is postoperative day 3 after right total knee arthroplasty. He has hypertension treated with amlodipine; preoperative BP was 132/80 and HR 78. He reports daily heavy alcohol use for 30 years, and his last drink was the morning of admission. Family reports no known withdrawal seizures or prior withdrawal delirium. Tonight he says insects are crawling on the wall and has tried twice to climb out of bed. He is oriented to person only, and attention drifts. Findings: BP 168/96 and HR 124, RR 22, T 38.2 C, and SpO2 95 percent on room air. He has a coarse hand tremor with diaphoresis. He rates knee pain 3/10 at rest and received oxycodone 5 mg 6 hours ago. There is swelling and bruising around the incision. This morning's hemoglobin is 11.2 g/dL, down from 13.0 before surgery.

## Explanation

The last drink on the morning of admission places this POD 3 client at about 72 hours, the window for withdrawal delirium, which is the context that ties the current findings together. Visual hallucinations, disorientation with fluctuating attention, coarse tremor with diaphoresis, and BP 168/96 with HR 124 against a preoperative 132/80 and 78 show delirium with autonomic hyperactivity. Pain rated 3/10, a small oxycodone dose 6 hours ago, expected incisional swelling, and an expected postoperative hemoglobin drop do not explain an agitated, hyperadrenergic delirium.

## In-depth explanation

Quick answer
Highlight the insects on the wall, disorientation with drifting attention, BP 168/96 with HR 124, and coarse tremor with diaphoresis.

Why this is correct
POD 3 after a last drink on the morning of admission is about 72 hours after cessation, squarely in the 48- to 96-hour window for withdrawal delirium. Visual hallucinations plus inattention and disorientation define an acute delirium, and tremor, sweating, hypertension, and tachycardia well above his preoperative 132/80 and 78 show autonomic hyperactivity. Together they need rapid-response evaluation and safety measures; the last-drink timing is unselectable history that explains why this pattern is emerging now.

Easy analogy or mental picture
Picture a car whose accelerator was held down by alcohol for 30 years. Remove the alcohol and the engine over-revs: racing pulse, high BP, shaking, sweating, and a mind that cannot hold focus.

Memory hook
Day 3 after the last drink plus shakes, sweats, and bugs on the wall equals withdrawal delirium until proven otherwise.

NCLEX decision rule
For new confusion after surgery, look for the cause that fits both the timing and the vital-sign pattern. Hyperadrenergic delirium with hallucinations does not come from controlled pain, a small remote opioid dose, or expected surgical findings.

Why the other choices are wrong
Knee pain 3/10 is controlled, so pain-driven agitation does not fit. Oxycodone 5 mg given 6 hours ago would more likely cause sedation and slow breathing, not tachycardia, tremor, and hallucinations, though medication effects remain on the differential. Swelling and bruising around a knee incision on POD 3 are expected. A hemoglobin of 11.2 after 13.0 preoperatively is an expected arthroplasty blood loss without instability. SpO2 95 percent is acceptable, and the absence of prior withdrawal seizures is reassuring history, not a current danger sign.

References
1ASAM Clinical Practice Guideline on Alcohol Withdrawal ManagementWithdrawal delirium typically emerges about 48 to 96 hours after the last drink with autonomic hyperactivity, tremor, and hallucinations
2Alcohol Withdrawal (StatPearls, NCBI Bookshelf)Timing after cessation, tremor, diaphoresis, tachycardia, hypertension, and disorientation distinguish severe withdrawal

## Clinical scenario

Scenario (Stage 1 — Recognize cues)
On postoperative day 3 after knee arthroplasty, a client with long-standing heavy alcohol use becomes acutely confused and agitated.

Clinical judgment target
Distinguish the withdrawal-timed delirium and autonomic cues from expected postoperative findings, controlled pain, and low-risk medication exposure.

## Key concepts

- **Alcohol withdrawal delirium** — Severe withdrawal with disturbed attention and awareness, hallucinations, and autonomic hyperactivity, usually 48 to 96 hours after the last drink.
- **Autonomic hyperactivity** — Sympathetic overdrive shown by tachycardia, hypertension, diaphoresis, tremor, and sometimes fever.
- **Postoperative delirium** — An acute fluctuating disturbance of attention after surgery that can arise from pain, drugs, infection, hypoxia, or metabolic causes.

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