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NCLEX · Substance Use Disorders

A 45-year-old client is admitted for alcohol withdrawal monitoring. Which scale is used to standardise assessment and guide benzodiazepine dosing in alcohol withdrawal?

Correct answer

Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) — a 10-item scale assessing autonomic symptoms (HR, BP), tremor, diaphoresis, agitation, and hallucinations; scores guide symptom-triggered benzodiazepine administration (e.g., lorazepam if CIWA-Ar > 8-10)

  1. A PHQ-9
  2. B Glasgow Coma Scale
  3. C Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) — a 10-item scale assessing autonomic symptoms (HR, BP), tremor, diaphoresis, agitation, and hallucinations; scores guide symptom-triggered benzodiazepine administration (e.g., lorazepam if CIWA-Ar > 8-10)
  4. D CAGE questionnaire

Why this is the answer

CIWA-Ar SCALE: THE STANDARD: Most commonly used validated tool for alcohol withdrawal monitoring; ITEMS: Nausea/vomiting; tremor; diaphoresis; anxiety; agitation; tactile disturbances (formication); auditory disturbances; visual disturbances; headache; orientation/clouding; SCORING: 0-67 total; INTERPRETATION: <10: Mild — monitoring, no medication unless symptoms progress; 10-15: Moderate — consider benzodiazepine; >15: Severe — benzodiazepine required; >20: Risk for delirium tremens; SYMPTOM-TRIGGERED vs FIXED SCHEDULE: CIWA-Ar allows symptom-triggered dosing — only administer benzodiazepine when score exceeds threshold (reduces total benzodiazepine dose, shortens withdrawal duration, improves safety vs fixed schedule); NURSING ROLE: Assess CIWA-Ar every 1-4 hours per protocol; administer PRN benzodiazepines per orders when threshold reached; monitor vital signs; ensure IV access; COMPARE: CAGE questionnaire = screening tool (Cut-down, Annoyed, Guilty, Eye-opener) for AUD history — not for acute withdrawal monitoring.
Source: NCLEX-RN Psychosocial — Substance Use, CIWA-Ar Alcohol Withdrawal Monitoring

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