The nurse is caring for a client who is experiencing marked confusion, unsteady gait and diplopia after being admitted to the hospital for alcohol withdrawal. Which of the following nursing interventions is the priority for the nurse to implement?
1. Encourage adequate nutrition and fluids.
2. Administer prescribed thiamine.
3. Provide safety measures.
4. Administer prescribed benzodiazepine.
Please don't consult any books, and answer it right away as you would do on the actual exam. I'm curious if it's a hard question or if I have poor critical thinking skills (well, they are poor, but I want to know how poor).
May 3, '07
Hmm that's tough but then it's simple at the same time. I would be inclined to say #3 safety.
I had an instructor that said "First make sure they are breathing. Then make sure than are safe and waht are going to do or not do won't kill them." Doesn't sound like this pt. is having ABC issues now but it DOES sound like he/she may fall down cracking their head and causing what that same instructor called ABC"B" (airway, breathing, circulation and BLOOD BLOOD... BLOOD is BAD. She sang it though it was pretty funny). Benzos, in my understanding, are used to treat/prevent seizure. I be more worried about the pt. hurting themselves at this point.
Do tell.. what does the "book" say?
Last edit by JoniL&DRN on May 3, '07