Nursing Prioritization Delegation Assignment Q 23
A drunk driver has been in the police station for 48 hours. During the first hours, he had tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation, hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What is the priority nursing diagnosis?
A. Risk for Nutritional Deficit related to chronic alcohol abuse
B. Risk for Injury related to seizures
C. Risk for Situational Low Self-Esteem related to police custody
D. Risk for Other-Directed Violence related to hallucinations
Correct Answer: B. Risk for Injury related to seizures
Client safety is the priority because the driver exhibits neurologic hyperactivity and is on the verge of a seizure. Medications such as chlordiazepoxide (Librium) are needed to decrease neurologic irritability and phenytoin (Dilantin) for seizures. Thiamine and haloperidol (Haldol) may also be ordered to treat other problems.
Option A: If withdrawal symptoms remain untreated, this can typically lead to DT. Additional evaluation of a patient with DT involves identifying electrolyte, nutrition, and fluid abnormalities. Most of these patients present with severe dehydration (up to 10 L fluid deficit) and severe electrolyte abnormalities, including hypoglycemia and severe hypomagnesemia and hypophosphatemia.
Option C: Delirium tremens occur in chronic alcohol abusers who abruptly discontinue alcohol use, often as early as 48 hours. The initial minor withdrawal symptoms are characterized by anxiety, insomnia, palpitations, headache, and gastrointestinal symptoms. These symptoms usually occur as early as 6 hours after cessation of alcohol use. More than 50% of those with a history of alcohol abuse can exhibit alcohol withdrawal symptoms at discontinuing or decreasing their alcohol use.
Option D: After 12 hours, minor withdrawal symptoms can progress to alcohol hallucinosis, a condition characterized by visual hallucinations. It can typically resolve in 24 to 48 hours, and may also be associated with auditory and tactile hallucinations.