Mental Health Question #19

Question

The nurse is caring for a client with alcohol-withdrawal delirium. The nurse determines which action has the highest priority?

Answers

  1. Allow for venting of feelings and reasons for drinking.
    • Rationale:
  2. Administer fluids and electrolyte replacement.
    • Rationale:
  3. Provide reality orientation.
    • Rationale:
  4. Make a referral for social services for Alcohol Anonymous placement.
    • Rationale:

Overview

Explanation

The highest priority is connected to Maslow’s Hierarchy of needs since alcohol delirium may be a life-threatening condition with loss of fluids and electrolytes. Options A and D can be performed after the threatening physiological condition is stabilized. Option C is important with assessment; however, it is not the priority intervention to maintain life.

Learning Outcomes

Test Taking Tip

Video Rationale