Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal?

Correct Answer: A. Heart rate of 120 to 140 beats/minute

Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don’t receive treatment. The nurse should monitor the client’s vital signs carefully throughout the entire alcohol withdrawal process.

• Option B: Delirium tremens is the most severe form of alcohol withdrawal, and its hallmark is that of an altered sensorium with significant autonomic dysfunction and vital sign abnormalities. It includes visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. Symptoms of delirium tremens can last up to seven days after alcohol cessation and may last even longer.
• Option C: Alcohol withdrawal can range from very mild symptoms to the severe form, which is named delirium tremens. The hallmark is autonomic dysfunction resulting from the excitation of the central nervous system. Mild signs/symptoms can arise within six hours of alcohol cessation. If symptoms do not progress to more severe symptoms within 24 to 48 hours, the patient will likely recover.
• Option D: Patients should be kept calm in a controlled environment to try to reduce the risks of progression from mild symptoms to hallucinations. With mild to moderate symptoms, patients should receive supportive therapy in the form of intravenous rehydration, correction of electrolyte abnormalities, and have comorbid conditions as listed above ruled out.