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    ATI PN Mental Health Proctored Exam 2023 II

    A nurse is contributing to the plan of care for a client who is experiencing severe alcohol withdrawal.Which of the following interventions should the nurse contribute to the plan of care?

    Explanation & Rationale

    Choice A rationaleEncouraging ambulation for a client experiencing severe alcohol withdrawal could be unsafe due to potential instability, tremors, and the risk of falls. Severe withdrawal often involves motor incoordination and impaired balance. The priority is to provide a safe and quiet environment to minimize stimulation and prevent injury.Choice B rationaleBenztropine is an anticholinergic medication primarily used to treat extrapyramidal symptoms, often associated with antipsychotic medications. It is not a standard treatment for alcohol withdrawal and could potentially worsen some withdrawal symptoms like confusion and tachycardia.Choice C rationaleIncreasing the temperature in the client's room is contraindicated as it can exacerbate diaphoresis, a common symptom of alcohol withdrawal, leading to dehydration and electrolyte imbalances. A cool and well-ventilated environment is generally recommended for these clients.Choice D rationaleSevere alcohol withdrawal can lead to seizures due to the brain's maladaptation to chronic alcohol exposure and subsequent hyperexcitability upon cessation. Implementing seizure precautions, such as padding the bed rails and having suction equipment readily available, is crucial to ensure the client's safety.

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