# A 58-year-old client is on postoperative day 4 after elective hip arthroplasty. Since this morning the client has become disoriented, pulls at lines, and reports insects crawling on the wall. Temperature is 38.6 C, heart rate 132/min, BP 168/96 mm Hg, respirations 24/min, and the client is markedly diaphoretic with a coarse hand tremor. The incision is clean and dry, lungs are clear, and urinalysis is negative. Eye movements are full without nystagmus. The client was sleeping 6 to 7 hours nightly until last night. Opioid use has been limited to oral doses for incision pain. The family reports daily heavy alcohol use; the last drink was before admission. 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=617401&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

A 58-year-old client is on postoperative day 4 after elective hip arthroplasty. Since this morning the client has become disoriented, pulls at lines, and reports insects crawling on the wall. Temperature is 38.6 C, heart rate 132/min, BP 168/96 mm Hg, respirations 24/min, and the client is markedly diaphoretic with a coarse hand tremor. The incision is clean and dry, lungs are clear, and urinalysis is negative. Eye movements are full without nystagmus. The client was sleeping 6 to 7 hours nightly until last night. Opioid use has been limited to oral doses for incision pain. The family reports daily heavy alcohol use; the last drink was before admission. 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
Postoperative delirium from sleep deprivation
Sepsis-associated delirium
Wernicke encephalopathy
Alcohol withdrawal delirium

Actions to take

Select 2
Give IV benzodiazepines per withdrawal protocol
Start empiric broad-spectrum IV antibiotics
Give the prescribed high-dose IV thiamine
Give haloperidol as the sole agent for agitation
Apply four-point restraints to protect the lines

Parameters to monitor

Select 2
Blood culture results at 48 hours
Eye movements and gait
Heart rate and blood pressure
Hours of nighttime sleep
RASS sedation-agitation score

## Explanation

Acute disorientation and visual hallucinations with fever, tachycardia, hypertension, tremor, and diaphoresis about 4 days after the last drink, with no infectious source found, indicate alcohol withdrawal delirium. The nurse gives IV benzodiazepine per the severe-withdrawal protocol and the prescribed high-dose IV thiamine. Heart rate with BP and an observer-rated sedation-agitation score show response because a delirious client cannot give a reliable self-report.

## In-depth explanation

Quick answer
Condition: alcohol withdrawal delirium. Actions: give IV benzodiazepines per withdrawal protocol and give the prescribed high-dose IV thiamine. Monitor: heart rate and blood pressure, and RASS sedation-agitation score.

Why this is correct
Withdrawal delirium typically begins 48 to 96 hours after the last drink and combines a fluctuating confusional state, often with visual hallucinations, with autonomic hyperactivity (fever, tachycardia, hypertension, sweating, tremor). It is a medical emergency; benzodiazepines treat the underlying GABA deficit. Heavy daily drinking depletes thiamine, so IV thiamine is given to prevent Wernicke encephalopathy without delaying any glucose the client needs. Autonomic signs and an observer-rated scale such as RASS guide dose titration.

Easy analogy or mental picture
Alcohol has been holding the brake down for years; take it away suddenly and the engine races (heart rate, BP, fever, hallucinations). Benzodiazepines put a foot back on the brake while the system recalibrates.

Memory hook
Day 2 to 4 without a drink + racing vitals + seeing bugs = benzo now, thiamine too.

NCLEX decision rule
In severe withdrawal, treat with the protocol-directed drug rather than symptom-only agents, and use objective measures when the client cannot give a reliable self-report.

Why the other choices are wrong
Postoperative sleep-deprivation delirium shares confusion but not fever, BP 168/96, tremor, and diaphoresis, and the client slept normally until last night, so tracking sleep hours misses the driver. Sepsis-associated delirium is tempting because of fever and tachycardia, but the incision is clean, lungs are clear, and urinalysis is negative, so empiric antibiotics and blood-culture results follow the wrong cause. Wernicke encephalopathy shares the alcohol history and confusion but lacks ophthalmoplegia and an autonomic storm; eye movements and gait follow that differential. Haloperidol alone does not treat withdrawal and can lower the seizure threshold. Restraints are a last resort after less restrictive measures and increase agitation and injury risk.

References
1ASAM — Clinical Practice Guideline on Alcohol Withdrawal ManagementBenzodiazepines as first-line treatment, thiamine for patients with alcohol withdrawal, and objective scales for delirious patients

## Clinical scenario

Scenario
Postoperative day 4: acute delirium with visual hallucinations and autonomic hyperactivity after abrupt cessation of heavy drinking.

## Key concepts

- **Alcohol withdrawal delirium** — Severe withdrawal with disturbed attention and consciousness plus autonomic hyperactivity, usually 48 to 96 hours after the last drink.
- **RASS** — Richmond Agitation-Sedation Scale, an observer-rated score from combative (+4) to unarousable (-5).
- **Thiamine** — Vitamin B1; given to prevent or treat Wernicke encephalopathy in clients with heavy alcohol use.

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