Page 2311 - Saunders Comprehensive Review For NCLEX-RN

▪ Easily startled

▪ Hyperalertness
▪ Hypertension
▪ Insomnia
▪ Irritability
▪ Jerky movements
▪ Possibly experiences hallucinations, illusions, delusions, or vivid nightmares
▪ Possibly reports a feeling of “shaking inside”
▪ Seizures (usually appear 7 to 48 hours after cessation of alcohol)
▪ Tachycardia
▪ Tremors

Box 66-3

Manifestations of Alcohol Withdrawal Delirium
(Delirium Tremens)

▪ Agitation
▪ Anorexia
▪ Anxiety
▪ Delirium
▪ Diaphoresis
▪ Disorientation with fluctuating levels of consciousness
▪ Fever (temperature of 100° F [37.8° C] to 103° F [39.4° C])
▪ Hallucinations and delusions
▪ Insomnia

▪ Tachycardia and hypertension

Box 66-4

Managing the Client Who Misuses Alcohol

▪ Direct the client’s focus to the substance misuse problem.
▪ Identify situations that precipitate angry feelings with the client.

▪ Set limits on manipulative behavior and verbal and physical abuse.
▪ Hold the client firmly accountable to reasonable limits, consistently reinforcing
rules, with reasonable consequences for breaking rules.

▪ Hold the client accountable for all behaviors.
▪ Use motivational interviewing to assist the client to explore strengths and
weaknesses.

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