8. Clients who are dependent on alcohol and experience withdrawal are at risk for physical problems. Which independent nursing actions should be conducted during the detoxification phase when caring for this client? Select all that apply.
8. Clients who are dependent on alcohol and experience withdrawal are at risk for physical problems. Which independent nursing actions should be conducted during the detoxification phase when caring for this client? Select all that apply.
. Assess vital signs every 4 hours and as needed.
. Place the client on seizure and fall precautions.
. Administer benzodiazepines and anticonvulsants.
. Increase the intravenous rate to match serum sodium levels.
. Restrain the client if hallucinations are present.
Test-Taking Tip
Remember independent nursing actions (e.g., vital signs and all precautions) do not require a physician's order.
Content Area: Mental Health, Substance Abuse; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Chemical and Other Dependencies
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Answer 1 is correct because the client may experience increases in vital signs (e.g., pulse and blood pressure). Answer 2 is correct because it is important to place the client on seizure precautions as these occur during withdrawal. The nurse must place the client on fall precautions to prevent injury if the client becomes confused. Answer 3 is incorrect because this action requires a physician's order. Answer 4 is incorrect because this action requires a physician's order. Answer 5 is incorrect because this action requires a physician's order.