A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?

A. When a nurse observes illegal or unethical behavior, such as stealing narcotics, it is their ethical and legal responsibility to report the incident promptly to the appropriate authorities.

B. While it's important to encourage the coworker to seek treatment for their substance abuse issue, withholding reporting of the incident compromises patient safety and violates organizational policies and legal obligations. It's essential to report the incident regardless of the coworker's actions afterward.

C. Reporting the incident to other RNs on the shift may not be sufficient action to address the seriousness of the situation. While it's important for colleagues to be aware of potential risks to patient safety, the primary responsibility lies with reporting the incident to the appropriate authorities within the organization.

D. Agreeing not to report the incident in exchange for the coworker promising to report themselves to the supervisor is not an appropriate course of action. It's essential to follow established reporting protocols and ensure that the incident is documented and addressed through the appropriate channels to protect patient safety and uphold professional standards.

C. Dementia related to a traumatic brain injury can result in a variety of cognitive and physical impairments. A shuffling gait, characterized by short steps with feet barely leaving the ground, is often associated with Parkinsonian symptoms, which can occur in advanced stages of dementia or as the condition progresses. Therefore, a shuffling gait would indicate worsening of the client's condition.

A. While visual disturbance can occur in individuals with dementia, visual field cuts alone may not necessarily indicate worsening of the condition unless they are accompanied by other concerning symptoms.

B. CD4 counts are a measure of immune system function, particularly in relation to HIV/AIDS. Decreased CD4 counts are not typically associated with dementia related to traumatic brain injury and would not be a relevant finding in this context.

D. Chorea is not a common feature of dementia related to traumatic brain injury. The presence of chorea may indicate a different underlying neurological condition or complication