Difficulty: Medium
Average Score: 93%
Simulated
A client has been admitted to the emergency department with alcohol withdrawal delirium. At 9 a.m. on 10/25, the nurse notes that the client is confused. His vital signs are T=99┬░F, P=50, R=10, and BP=100/60. The nurse compares these findings to the nurses' progress notes from admission 24 hours ago. What should the nurse do first?
Correct answer
C
Rationale
Attempting to arouse the client is the first action, as it assesses the level of consciousness and responsiveness, critical in determining the severity of delirium and guiding further interventions.