A nurse in a substance treatment facility is contributing to the plan of care for a newly admitted client. Which of the following interventions should the nurse recommend? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)
Explanation & Rationale
A. Administer disulfiram: Disulfiram is used for long-term management to discourage alcohol use by causing unpleasant reactions if alcohol is consumed. It is not appropriate during acute alcohol withdrawal, as it does not treat withdrawal symptoms and could be harmful if the client relapses. B. Complete a CAGE questionnaire every 4 hr: The CAGE questionnaire is a screening tool for identifying alcohol use disorder but is not used for ongoing monitoring of acute withdrawal. Repeating it every 4 hours does not address the immediate clinical needs or risks during withdrawal. C. Implement seizure precautions: The client exhibits classic signs of alcohol withdrawal, including tremors, diaphoresis, elevated BP, tachycardia, nausea, and anxiety. Severe withdrawal can progress to seizures and delirium tremens. Implementing seizure precautions is essential to prevent injury and ensure safety during acute withdrawal management. D. Assist with a client referral to Al-Anon: Al-Anon provides support for family members of individuals with alcohol use disorder. While valuable for long-term support, it does not address the client’s acute withdrawal risks and is not the priority intervention during the initial phase of treatment.