A hospitalized patient, injured in a fall while intoxicated, believes spiders are spinning entrapping webs in the room. The patient is anxious, agitated, and diaphoretic. Which nursing intervention has priority?
A) Check the patient every 15 minutes.
B) Rigorously encourage fluid intake.
C) Provide one-on-one supervision.
D) Keep the room dimly lit.

Question

Quizplus · Accepted Answer

This patient is experiencing alcohol withdrawal delirium. One-on-one supervision is necessary to promote physical safety until sedation reduces the patient's feelings of terror. Checks every 15 minutes would not be sufficient to provide for safety. A dimly lit room promotes illusions. Oral fluids are important, but safety is a higher priority.

A Hospitalized Patient, Injured in a Fall While Intoxicated, Believes