Which of the following should the nurse incorporate into the care ...

[tichca]

Which of the following should the nurse incorporate into the care plan of a client demonstrating symptoms of withdrawal delirium?
 
  1. Encourage group participation.
  2. Confront denial of substance abuse.
  3. Use restraints on all extremities.
  4. Create quiet, nonstimulating environment.

Question 2

The priority outcome for a client who has been admitted for detoxification from alcohol after a 20-year history of drinking and enablement by her family would be that the client will:
 
  1. Have vital signs within normal range
  2. Identify the effect alcohol has had on her life
  3. Join a 12-step support group
  4. Commit to remaining alcohol-free

[jessofishing]

Answer to Question 1

ANS: 4
Group participation and confrontation are not appropriate during withdrawal delirium, so options 1 and 2 are incorrect. Use of restraints is not safe at this time (option 3), and the quiet environ-ment (option 4) is best.

Answer to Question 2

ANS: 1
During detoxification, which can be life-threatening, the most important thing is normal vital signs (option 1). The other activities can take place after detoxification.