Comprehensive exams for Mental Health Q 96
A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time?
A. Keeping the client restrained in bed.
B. Checking the client’s blood pressure every 15 minutes and offering juices.
C. Providing a quiet environment and administering medication as needed and prescribed.
D. Restraining the client and measuring blood pressure every 30 minutes.
Correct Answer: C. Providing a quiet environment and administering medication as needed and prescribed.
Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Encourage the patient to rest by controlling minimal interpersonal contact with the patient. Decrease environmental stimuli with controlled lighting, and provide a calm, quiet private room. The individualized, symptom-triggered approach to benzodiazepine use satisfies the need to use medication only when needed and may also reduce inpatient hospital stays. Benzodiazepines stimulate GABA receptors causing a decrease in neuronal activity resulting in sedation.
Option A: Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Present reality without challenging or escalating the patient’s anxiety and thought disturbances. Build a therapeutic rapport with the patient by providing relief from his or her symptoms and meeting physiologic and safety needs. Meet the patient’s needs promptly to reduce the risk of violence or aggression. Do not approach the patient with loose items that the patient could grab if he or she becomes agitated, such as a clipboard or dangling ID badge or phone.
Option B: Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client’s rest. The nurse also documents the patient’s vital signs, looking for an upward trend indicating increased withdrawal symptoms. On a scale of 0 (none) to 3 (severe), the nurse then rates key signs and symptoms such as nausea/vomiting; tremors; diaphoresis; anxiety; agitation; tactile, auditory, and visual disturbances; headache; and orientation.
Option D: To avoid overstimulating the client, the nurse should check blood pressure every 2 hours. As direct caregivers, nurses are ideally positioned to improve patient outcomes by using the symptom-triggered approach. Based on an objective withdrawal severity scale, a symptom-triggered approach provokes faster and more-effective relief of withdrawal symptoms than treatment based on clinicians’ subjective judgment alone.