A nurse is providing teaching to a client who has depressive disorder and a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching?

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. Document the client's behavior hourly on a flow sheet: While documentation is important, it is more frequent than hourly. Clients in restraints should be observed and documented on more frequently, usually every 15 minutes to ensure safety and assess the client's condition.

B. Request a PRN client prescription for restraints from the provider: Restraints require a specific order from the provider, not a PRN (as needed) prescription. The order must be obtained initially and renewed per the facility's policy, typically every 24 hours.

C. Observe the client's behavior once every 15 minutes: Clients in restraints must be closely monitored for safety and well-being. The nurse should assess the client’s condition, including physical and emotional status, every 15 minutes.

D. Remove the restraint when the client calmly follows commands: Restraints should only be removed under appropriate conditions as assessed by the nurse, and with a provider’s order when necessary. The client's behavior alone does not determine the removal of restraints.