Practice Quiz

NCLEX-RN

Category - Physiological

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A nurse is visiting a client who was recently hospitalized for alcohol withdrawal. The client is in the tremulous stage. Which of the following interventions should be done to ensure safety?
  1. Administer PRN sedatives.
  2. Ensure that a tongue-depressor is available at bedside at all times.
  3. Lightly restrain the extremities to avoid further injury.
  4. Surround the client with soft pillows or blankets.
Explanation
Answer: D - The nurse should appropriately identify the safety hazards. When caring for this client, the best intervention is to provide soft barriers around the bed to avoid injury to the hands, arms and legs. The tremulous stage of alcohol withdrawal is characterized by tremors of the hands, arms and legs, accompanied by anxiety and agitation. The nurse should reserve chemical (A) and physical modalities (C) in restraining the client. A padded tongue depressor may be used cautiously during seizures.
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