1. A nurse is caring for a client who has alcohol use disorder. Vital Signs Day 1: Blood pressure 118/78 mm Hg Heart
1. A nurse is caring for a client who has alcohol use disorder. Vital Signs Day 1: Blood pressure 118/78 mm Hg Heart rate 94/min Respiratory rate 18/min Temperature 36.9° C (98.4° F) Oxygen saturation 98% on room air Day 3: Blood pressure 152/104 mm Hg Heart rate 118/min Respiratory rate 20/min Temperature 38.1° C (100.6° F) Oxygen saturation 97% on room air. Physical Examination Day 1: Client awake and alert. Heart rate regular, lungs clear bilaterally. Abdomen soft, nondistended, bowel sounds active in all four quadrants. No edema. Last alcoholic drink consumed approximately 14 hr ago. Mild hand tremors noted. Reports not sleeping well and waking up with mild nausea. Ate 10% of breakfast. Day 3: Client sitting on the bed, is anxious, restless, and diaphoretic. Client states, “Stay back! There’s a rattlesnake under the bed. I heard it rattling all night when I couldn’t sleep. I think I felt it crawling on me earlier, so I laid really still. I need a knife or something to try and kill it.” Speech is rapid and rambling, unable to focus to answer questions. Did not eat breakfast, client states, “I am sick to my stomach.” Intake is 120 mL; output
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