Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5010

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5010

QUESTION: A client begins to experience alcoholic hallucinosis. What is the best nursing intervention at this time?

✘O a.) Keeping the client restrained in bed
✘O b.) Checking the client's blood pressure every 15 minutes and offering juices
✓O c.) Providing a quiet environment and administering medication as needed and prescribed
✘O d.) Restraining the client and measuring blood pressure every 30 minutes

RATIONALE

RATIONALE: Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to reduce stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation. Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge