The nurse is monitoring a patient who abuses alcohol for signs of alcohol withdrawal. Which of the following signs would alert the nurse that withdrawal delirium has developed in the patient?

1. A

   Hypertension, ataxia, increased appetite

2. B

   Shunt, agitation and muscle rigidity

3. C

   Hypotension, hand tremors, agitation

4. D

   Anxiety, hypertension, agitation, tachycardia

Appeared in: RML 2023

Explanation

• Alcohol withdrawal delirium, or delirium tremens (DTs), is the most severe form of alcohol withdrawal and is a medical emergency.
• It is caused by the abrupt cessation of alcohol, which acts as a central nervous system (CNS) depressant. This leads to a rebound state of CNS and autonomic nervous system hyperactivity.
• This hyperactivity manifests as a cluster of symptoms including anxiety, agitation, hypertension (elevated blood pressure), and tachycardia (rapid heart rate).
• Other signs include confusion, disorientation, hallucinations (especially tactile), and profuse sweating (diaphoresis).

Why Other Options Were Wrong

• Option A: While hypertension is a sign of withdrawal delirium, increased appetite is incorrect; patients typically experience anorexia (loss of appetite). Ataxia (impaired coordination) is more commonly associated with Wernicke's encephalopathy.
• Option B: The term 'shunt' is not relevant to the signs of alcohol withdrawal. While agitation is correct, muscle rigidity is not a characteristic feature; tremors are far more common.
• Option C: This option incorrectly lists hypotension (low blood pressure). Due to autonomic hyperactivity, the patient would exhibit hypertension (high blood pressure).

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Signs and Symptoms of Alcohol Withdrawal Delirium (Delirium Tremens) to guide bedside assessment, documentation, and the next nursing action.
• Recognizing the signs of delirium tremens is a critical nursing responsibility because it is a life-threatening condition with a mortality rate as high as 20% if left untreated.
• Prompt initiation of treatment, typically with benzodiazepines (like diazepam or lorazepam) based on a standardized protocol (e.g., CIWA-Ar scale), is essential to manage symptoms and prevent complications like seizures and cardiovascular collapse.
• What if? If the patient had a co-existing infection like pneumonia, the risk of developing delirium tremens would be significantly higher, and the symptoms could be more severe. The nurse must assess for and manage concurrent illnesses.

How to Approach the Question

• First, identify the core clinical concept in the question stem, which is 'withdrawal delirium' in a patient who abuses alcohol.
• Recall the basic pathophysiology: Alcohol is a CNS depressant. Therefore, abrupt withdrawal will cause a rebound CNS hyperactivity or overstimulation.
• Based on this 'hyperactivity' model, predict the expected signs and symptoms. You should anticipate signs of an overactive sympathetic nervous system: high heart rate (tachycardia), high blood pressure (hypertension), agitation, and anxiety.
• Systematically evaluate each option. Look for the option that presents a cluster of symptoms consistent with a hyper-adrenergic state.
• Eliminate options that contain contradictory signs (e.g., hypotension) or signs not characteristic of withdrawal delirium (e.g., increased appetite, muscle rigidity).

Concept Tested & Keywords

• Concept Tested: Signs and Symptoms of Alcohol Withdrawal Delirium (Delirium Tremens)
• Stem keywords: alcohol withdrawal, withdrawal delirium, signs
• Lead-in keywords: alert the nurse
• Negative lead-in flag: false

Question ID

QXOhdFaJThTXZ6ACz6YpQg

Copy ID

Reference Book

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 891-893

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 p. 136-138