20. Which assessment findings should alert a nurse to early alcohol withdrawal in a client 2 days after surgery? Select all that apply.
20. Which assessment findings should alert a nurse to early alcohol withdrawal in a client 2 days after surgery? Select all that apply.
. Auditory hallucinations.
. Decreased blood pressure.
. Depression.
. Diaphoresis.
. Tachycardia
. Dilated pupils
Test-Taking Tip
Look for an early autonomic response.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
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Answer 1 is incorrect because hallucinations do occur but not initially. Answer 2 is incorrect because the vital signs are initially elevated. Answer 3 is incorrect because the client is agitated. Answer 4 is correct because the client will experience autonomic overactivity causing tachycardia, dilated pupils, and profuse perspiration. Answer 5 is correct because the autonomic overactivity will cause tachycardia. Answer 6 is correct because the pupils will be dilated from the autonomic overactivity.