# Stage 3 — Prioritize hypotheses. A 58-year-old client is on postoperative day 3 after right total knee arthroplasty. He reports daily heavy alcohol use for 30 years; his last drink was the morning of admission. 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 his attention drifts. BP is 168/96 (preoperative 132/80), HR 124, RR 22, temperature 38.2°C (100.8°F), and SpO2 95% on room air. He has a coarse hand tremor with diaphoresis. Pupils are equal and reactive, and eye movements are full without nystagmus. Knee pain is 3/10, and he received oxycodone 5 mg 6 hours ago. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617388&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

Stage 3 — Prioritize hypotheses. A 58-year-old client is on postoperative day 3 after right total knee arthroplasty. He reports daily heavy alcohol use for 30 years; his last drink was the morning of admission. 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 his attention drifts. BP is 168/96 (preoperative 132/80), HR 124, RR 22, temperature 38.2°C (100.8°F), and SpO2 95% on room air. He has a coarse hand tremor with diaphoresis. Pupils are equal and reactive, and eye movements are full without nystagmus. Knee pain is 3/10, and he received oxycodone 5 mg 6 hours ago. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Alcohol withdrawal delirium
Alcoholic hallucinosis
Wernicke encephalopathy
Postoperative opioid-induced delirium

Actions to take

Select 2
Give prescribed naloxone 0.4 mg IV
Give haloperidol alone to control hallucinations
Give the prescribed IV thiamine
Apply bilateral wrist restraints as the first safety measure
Give IV benzodiazepine per protocol toward light sleep

Parameters to monitor

Select 2
Knee pain intensity score
RASS sedation score
Pupil size
Respiratory rate
Extraocular movements and nystagmus

## Explanation

Disorientation with drifting attention, visual and tactile hallucinations, tremor, diaphoresis, hypertension, tachycardia, and low-grade fever about 72 hours after heavy drinking stopped indicate alcohol withdrawal delirium. The nurse gives protocol-guided IV benzodiazepine toward light somnolence and the prescribed IV thiamine, which clients with long-term heavy alcohol use need in withdrawal. RASS tracks agitation and sedation, and respiratory rate watches for benzodiazepine-related respiratory depression.

## In-depth explanation

Quick answer
Alcohol withdrawal delirium. Give IV benzodiazepine per protocol toward light sleep and give the prescribed IV thiamine. Monitor the RASS score and respiratory rate.

Why this is correct
Delirium tremens typically starts 48 to 96 hours after the last drink, which matches this postoperative day 3 timing. The client has delirium (disorientation, drifting attention) plus autonomic hyperactivity (hypertension, tachycardia, fever, diaphoresis, tremor), the combination that defines withdrawal delirium. Benzodiazepines treat the underlying GABA deficit, and 30 years of heavy drinking leaves thiamine stores depleted, so IV thiamine is given to prevent Wernicke encephalopathy. A delirious client needs objective sedation scoring and close respiratory observation during benzodiazepine titration.

Easy analogy or mental picture
Years of alcohol act like a heavy foot on the brain's brake. When the alcohol stops, the foot lifts and the engine races: shaking, sweating, racing heart, and a mind that loses track of reality. Benzodiazepines put a foot back on the brake, and thiamine refuels a tank that heavy drinking has emptied.

Memory hook
"Day 2 to 4 after the last drink + confused + racing vitals = DTs." Benzo to light sleep plus thiamine, then watch RASS and breathing.

NCLEX decision rule
In suspected alcohol withdrawal delirium, treat the withdrawal with titrated benzodiazepines, give thiamine, and follow an objective sedation scale with respiratory monitoring during titration.

Why the other choices are wrong
Alcoholic hallucinosis also causes hallucinations after drinking stops, but the sensorium stays clear and vital signs are near normal; this client is disoriented with marked autonomic signs, so haloperidol alone would miss the withdrawal and lower the seizure threshold. Wernicke encephalopathy causes confusion with ophthalmoplegia or nystagmus and ataxia; eye movements are full, so extraocular movements do not track this client's progress. Opioid excess causes pinpoint pupils and slow breathing, not hypertension and tachycardia, so naloxone and pupil size do not fit. Knee pain is 3/10 and does not explain the delirium, so a pain score does not track it. Restraints as a first measure increase agitation and injury.

References
1ASAM Clinical Practice Guideline on Alcohol Withdrawal ManagementAlcohol withdrawal delirium requires monitored care, benzodiazepines titrated to light somnolence, and thiamine; antipsychotics are not stand-alone treatment
2StatPearls: Alcohol WithdrawalDelirium tremens typically begins 48 to 96 hours after the last drink with hallucinations, disorientation, and autonomic hyperactivity

## Clinical scenario

Case update
About 72 hours after his last drink, the client is disoriented with hallucinations, tremor, and autonomic hyperactivity.

## Key concepts

- **Delirium tremens** — Severe alcohol withdrawal with delirium and autonomic hyperactivity, usually 48 to 96 hours after the last drink.
- **RASS** — Richmond Agitation-Sedation Scale, an objective score from +4 (combative) to -5 (unarousable) used to titrate sedation.
- **Thiamine** — Vitamin B1; given IV to clients with long-term heavy alcohol use to prevent Wernicke encephalopathy.

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