A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Rationale for correct choices:

• Seizures: Seizures are a severe and life-threatening manifestation of alcohol withdrawal that require immediate intervention. They may lead to complications like injury or status epilepticus if not managed promptly.
• Increased blood pressure: Elevated blood pressure is a common sign of alcohol withdrawal and increases the risk of cardiovascular events such as stroke. Close monitoring and intervention are necessary to prevent complications.
• Increased heart rate: Tachycardia is commonly seen in alcohol withdrawal, increasing the risk of arrhythmias and cardiovascular stress. Management of heart rate is essential for maintaining stability.
• Diaphoresis: Diaphoresis, or excessive sweating, is part of the autonomic response during alcohol withdrawal and indicates significant distress in the body. It requires monitoring to ensure proper fluid and electrolyte balance.
• Vomiting: Vomiting in alcohol withdrawal can lead to dehydration and electrolyte imbalances, which can worsen the client’s condition. Immediate attention and interventions are needed to prevent further complications.
• Tremulousness: While often mild, tremors indicate CNS hyperexcitability and can escalate to more severe forms of withdrawal, including seizures or delirium tremens. It requires close monitoring and often pharmacological management to prevent progression.

Rationale for incorrect choices:

• Impaired cognition: Impaired cognition may occur due to alcohol intoxication or withdrawal but does not require immediate medical attention unless it is severe enough to affect the client’s ability to function or respond appropriately.
• Insomnia: Insomnia is common in alcohol withdrawal and can be distressing, but it is not life-threatening. It can be managed through appropriate therapeutic interventions but does not require urgent care.
• Lack of appetite: Loss of appetite is a common symptom of alcohol withdrawal and may be associated with gastrointestinal symptoms. It should be monitored but does not require immediate follow-up unless it leads to severe malnutrition.
• Malaise: Malaise is a general symptom of alcohol withdrawal and indicates a general sense of discomfort. It is important to monitor but does not require immediate intervention unless accompanied by more severe symptoms.

A. Ensure the client's room is dark at night: A dark room can increase confusion and agitation in clients with dementia, especially at night. It’s important to provide a well-lit environment to reduce confusion and help the client maintain a sense of orientation.
B. Use symbols to assist the client in finding personal items: Using symbols, pictures, or labels to help the client identify personal items can provide orientation and reduce frustration. This approach supports independence while minimizing confusion.
C. Ask the client orientation questions many times per day: Asking orientation questions repeatedly can increase anxiety and confusion for clients with dementia. It’s more effective to provide reassurance and support rather than focusing on constant questioning of orientation.
D. Provide a high level of sensory stimulation during the day: While some level of stimulation is important, excessive sensory input can overwhelm or agitate a client with dementia. The environment should be calm and soothing to avoid overstimulation.