Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5009

Substance Abuse, Eating Disorders, Impulse Control Disorders no. 5009

QUESTION: Which assessment finding is most consistent with early alcohol withdrawal?

✓O a.) Heart rate of 120 to 140 beats/minute
✘O b.) Heart rate of 50 to 60 beats/minute
✘O c.) Blood pressure of 100/70 mm Hg
✘O d.) Blood pressure of 140/80 mm Hg

RATIONALE

RATIONALE: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.
NURSING PROCESS STEP: Assessment
CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge