A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

Wandering behavior in clients with Alzheimer's disease poses a severe safety risk, frequently leading to falls, exposure to extreme weather, and getting lost. This behavior is often driven by confusion, a search for a familiar place, or an unmet physical need. Because clients with progressive cognitive decline lose the capacity to recognize environmental hazards, nursing interventions focus on modifying the home environment to secure exits without causing excessive agitation or restricting the client's physical freedom.

Rationale:

A. Installing complex locks at the top of all doors is the correct instruction to include. Clients with Alzheimer's disease tend to lose their complex problem-solving abilities, making specialized or double-locked mechanisms difficult for them to navigate. Furthermore, as the disease progresses, a client's visual field often narrows downward, causing them to miss things outside their direct line of sight. Placing locks high up near the top of the door frame keeps them out of the client's natural field of vision, effectively preventing them from opening external doors and wandering outside unattended.

B. Wearing a removable medical alert bracelet is an incorrect choice. While a medical identification bracelet is essential for ensuring a wandering client can be safely identified and returned home if they get lost, the bracelet must not be removable. A client with cognitive impairment can easily take off a removable bracelet, rendering it useless during an emergency. Instead, the family should utilize a permanent, non-removable ID bracelet or a secure tracking device.

C. Limiting physical activity during the day is an incorrect intervention. Restricting movement or forcing sedentariness can increase frustration, anxiety, and restlessness, which frequently exacerbates wandering behavior and sundowning (increased confusion and agitation in the late afternoon or evening). To promote better sleep patterns and reduce restless wandering, the family should encourage structured, safe physical activities during daylight hours, such as guided walks or simple household tasks.

D. Obtaining a hospital bed with side rails to use at night is an incorrect and unsafe instruction. Using full side rails on a bed for a client with cognitive impairment acts as a physical restraint. If a client with Alzheimer's disease decides to get out of bed while the rails are up, they will often attempt to climb over them. This significantly raises their center of gravity, exponentially increasing the risk of a dangerous fall from a greater height and causing severe injuries.

Assessment of a pregnant client at 31 weeks gestation requires rapid identification of findings suggestive of hypertensive disorders of pregnancy, particularly Preeclampsia. This condition is characterized by new-onset hypertension, proteinuria, and end-organ involvement that can affect both maternal and fetal well-being. Severe features such as persistent headache and reduced fetal movement indicate possible cerebral and placental compromise. Early recognition is essential to prevent progression to eclampsia, placental abruption, or fetal distress.

Rationale:
A. A blood pressure of 162/112 mmHg is severely elevated and is a defining feature of preeclampsia with severe features. This level of hypertension indicates significant vascular resistance and endothelial dysfunction associated with pregnancy-related hypertensive disorders. It places the client at risk for stroke, organ damage, and placental insufficiency requiring urgent intervention.

B. A severe headache unrelieved by acetaminophen is a concerning neurological symptom associated with worsening preeclampsia. It may indicate cerebral edema, vasospasm, or increased intracranial pressure. Persistent headache in this context is considered a warning sign of progression toward eclampsia and requires immediate evaluation.

C. Urine protein 3+ indicates significant proteinuria, which is a key diagnostic criterion for preeclampsia. This finding reflects glomerular endothelial damage leading to increased protein leakage into urine. The severity of proteinuria correlates with disease progression and maternal-fetal risk.

D. A respiratory rate of 16/min is within normal limits for pregnancy and does not indicate respiratory compromise. There are no associated signs of respiratory distress such as dyspnea or hypoxia. Therefore, this finding is not suggestive of a prenatal complication in this scenario.

E. Urine ketones are negative, indicating no evidence of starvation ketosis or metabolic imbalance. This finding is not associated with hypertensive pregnancy complications and does not suggest maternal or fetal risk in this context.

F. Decreased fetal movement is a significant warning sign of potential fetal compromise due to reduced placental perfusion. In hypertensive disorders like preeclampsia, vasoconstriction can impair oxygen and nutrient delivery to the fetus. This requires immediate fetal assessment to rule out distress.

G. Gravida 3 para 2 with one preterm birth is part of obstetric history but does not represent an acute prenatal complication. While it may indicate a slightly increased baseline risk for preterm delivery, it is not a current pathological finding requiring immediate intervention in this presentation.