Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5005

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5005

QUESTION: Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6<font face="LWWSYM">%</font> F (38.7<font face="LWWSYM">%</font> C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. The nurse should suspect:

✘O a.) a postoperative infection.
✓O b.) alcohol withdrawal.
✘O c.) acute sepsis.
✘O d.) pneumonia.

RATIONALE

RATIONALE: The client's vital signs and hallucinations suggest alcohol withdrawal delirium or alcohol withdrawal syndrome. Although infection, acute sepsis, and pneumonia may arise as postoperative complications, they wouldn't cause this client's signs and symptoms and typically would occur later in the postoperative course.
NURSING PROCESS STEP: Assessment
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension