42. A client, who abuses alcohol, is at risk for injury during the detoxification phase of alcohol withdrawal. Which physician order for this client should the nurse question?
42. A client, who abuses alcohol, is at risk for injury during the detoxification phase of alcohol withdrawal. Which physician order for this client should the nurse question?
. Apply soft wrist restraints as needed.
. Bedrest with side rails up.
. Maintain IV D5 0.45% NS at 100 mL/hr.
. Baseline ECG.
Test-Taking Tip
Restraints are never ordered on a prn basis; least restrictive approaches need to be tried first.
Content Area: Mental Health, Substance Abuse; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Advocacy
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Answer 1 is correct because it is inappropriate for the physician to order restraints as needed for any client. Answer 2 is incorrect because this is an appropriate order for a client detoxifying from alcohol due to the client's potential for confusion and a fall risk. Answer 3 is incorrect because this is an appropriate order for a client detoxifying from alcohol due to dehydration related to alcohol intake. Answer 4 is incorrect because this is an appropriate order for a client detoxifying from alcohol due to withdrawal complications related to increases in heart rate and risk for dysrhythmias.