A nurse is caring for a client who was hospitalized with a high blood alcohol content level. The provider fears the client may go into withdrawal and require medical supervision. The client's manifestations included anxiety, tremors, BP 166/100 mm Hg, and tachypnea about 1 hr ago. Now the client begins yelling out that they are seeing spiders crawling all over the walls. They believe they are at home and begin calling for their mother. The nurse should recognize that the client is experiencing which of the following stages of alcohol withdrawal?

Rationale: A. While hallucinations can occur in psychotic disorders, the timing, context, and recent high alcohol intake indicate that these symptoms are consistent with alcohol withdrawal. This is not primarily a psychiatric disorder in this scenario. B. Stage 2 alcohol withdrawal includes symptoms such as increased tremors, mild confusion, hypertension, tachycardia, and mild hallucinations (usually visual or auditory). However, in this case, the client is exhibiting severe hallucinations, disorientation, and agitation, which exceed moderate withdrawal criteria. C. Stage 1 is characterized by anxiety, mild tremors, restlessness, mild tachycardia, and insomnia. At this stage, hallucinations and severe disorientation are not present, so this does not fit the client’s presentation. D. Stage 3 alcohol withdrawal is marked by delirium tremens (DTs), which typically occurs 48–72 hours after the last drink but can appear earlier in some high-risk individuals. Symptoms include severe agitation, disorientation, visual and tactile hallucinations (e.g., seeing spiders), extreme confusion, autonomic hyperactivity (high BP, tachycardia, tachypnea), and fearfulness). The client in this scenario is exhibiting hallucinations, misperception of environment, disorientation, and physiologic instability, which are hallmark signs of severe alcohol withdrawal (Stage 3). Immediate medical supervision and intervention are required to prevent complications such as seizures, cardiovascular collapse, or injury.