Difficulty: Medium
Average Score: 81%
Simulated
A client on a stretcher in the emergency department begins to thrash around, slap the sheets and yells, 'Get these bugs off of me.' She is disoriented and has a blood pressure of 189/75 and a pulse of 96. The friend who is with her says, 'She was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn't have any.' The nurse should do the following in which order from first to last?
Correct answer
B, E, C, D, A, F
Rationale
The order is: 1) Constant observation for safety (B). 2) Remind client of hospital setting (E). 3) Monitor vital signs (C). 4) Administer medications (D). 5) Obtain restraint order if needed (A). 6) Chart response (F). Safety and orientation are prioritized, followed by treatment and documentation.