A client in alcohol withdrawal is assessed using the CIWA-Ar scale. Which score range indicates SEVERE withdrawal requiring close monitoring and aggressive pharmacological treatment?

The CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL (CIWA-Ar) is a 10-item standardized scale used to assess alcohol withdrawal severity and guide treatment. CIWA-Ar ITEMS (each scored 0-7, except orientation which is 0-4): nausea/vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile disturbances; auditory disturbances; visual disturbances; headache/fullness in head; orientation and clouding of sensorium. MAXIMUM SCORE: 67. SCORE INTERPRETATION: 0-9: MINIMAL withdrawal — monitor, possible oral benzodiazepines; 10-15: MILD-MODERATE — oral benzodiazepines (chlordiazepoxide, lorazepam, or diazepam per protocol); 15-20+: MODERATE-SEVERE — IV benzodiazepines, intensive monitoring; ≥20: SEVERE — high risk for DTs and seizures, may require ICU admission, IV diazepam or lorazepam, continuous monitoring. MEDICATION-GUIDED TREATMENT ('symptom-triggered'): benzodiazepines are given based on CIWA score rather than on a fixed schedule; has been shown to reduce total benzodiazepine use while maintaining safety. FIXED-DOSE SCHEDULES: some protocols use scheduled doses (q4-8h for 24-48 hours) with additional PRN doses for breakthrough symptoms. NURSING ROLE: assess CIWA-Ar every 1-4 hours during active withdrawal (frequency based on severity); administer benzodiazepines per score and protocol; monitor vital signs (BP, HR — elevated in withdrawal); monitor for progression to DTs; thiamine before glucose; IV fluids; seizure precautions; quiet, low-stimulation environment; one-to-one nursing for severe withdrawal. NEVER ABRUPTLY STOP ASSESSMENT — withdrawal progresses over time.