medium · NCLEX-RN Psychosocial Integrity

A client, Taylor, age 52, is experiencing alcohol withdrawal. The EHR shows a heart rate of 112/min, tremors, and new visual hallucinations.

Which intervention should the nurse execute first?

  1. Administer the prescribed benzodiazepine using the validated severity pathway.
  2. Ask the family to stay with the client to provide orientation, for this client.
  3. Apply soft wrist restraints to prevent the client from picking at the air.
  4. Provide 50% dextrose intravenously for reported weakness.

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