A nurse is planning care for a client who has a gambling disorder. Which of the following actions should the nurse include in the plan of care?

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.

Rationale:

• Heart rate: The client's heart rate has increased to 124 beats per minute, which is significantly higher than normal. This tachycardia could be a sign of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications like haloperidol.
• Temperature: The client's elevated temperature of 39.5°C (103.1°F) is concerning and could be indicative of NMS, which often presents with hyperthermia as one of its hallmark symptoms. NMS is a medical emergency that requires immediate attention.

Rationale for incorrect choices:

• Vision report: The client's report of blurry vision may be a side effect of haloperidol, but it is not typically considered a life-threatening reaction. It should be monitored but does not indicate an immediate crisis.
• Blood pressure: While the blood pressure is slightly low, it is not as critical as the combination of elevated heart rate and temperature. The low blood pressure would require monitoring but is not immediately indicative of a life-threatening reaction.
• Mouth report: Dry mouth is a common side effect of many medications, including antipsychotics like haloperidol. While uncomfortable, it is not a life-threatening condition.
• Respiratory rate: The respiratory rate of 22/min is within normal limits and does not indicate any immediate concerns related to the medication. It should be monitored but does not raise a red flag for a life-threatening reaction.