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    Med surg 2 proctored examQuestion 52
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    Med surg 2 proctored exam

    The client with a history of alcohol use is admitted to the hospital. Upon arrival anxiety, sweating, and tremors were noted. Now, disorientation, hallucination, and hyper-reactivity are observed. The medical diagnosis is delirium tremens. What is the priority nursing diagnosis?

    Explanation & Rationale

    A. Risk for Injury related to seizures is correct because delirium tremens (DTs) is the most severe form of alcohol withdrawal and can include life-threatening complications such as seizures, severe autonomic hyperactivity, and cardiovascular instability. Injury from seizures or falls is an immediate risk, making it the priority nursing diagnosis. In nursing, life-threatening risks take precedence over psychosocial or less acute concerns. B. Risk for Situational Low Self-esteem related to police custody is incorrect because while psychosocial issues may be relevant, they are not immediately life-threatening. The priority in DTs is stabilizing physical health and preventing injury. C. Risk for Nutritional Deficit related to chronic alcohol abuse is incorrect because although malnutrition is common in chronic alcohol users, this is a long-term risk, not the acute priority during DTs, where safety and seizure prevention come first. D. Risk for Other-Directed Violence related to hallucinations is incorrect because although hyperactivity and hallucinations can lead to agitation, the risk of physical injury from seizures is more urgent and potentially fatal. Behavioral management is important but secondary to preventing life-threatening complications.

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