Difficulty: Medium
Average Score: 94%
Simulated
Passage / Scenario
Nurses' Notes0230:
ÔÇó Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
Vital Signs
0200:
ÔÇó Temperature: 38.6┬░C (101.5┬░F)
ÔÇó Heart rate: 104/min
ÔÇó Respiratory rate: 18/min
ÔÇó Blood pressure: 158/96 mm Hg
ÔÇó Oxygen saturation: 98% on room air
0415:
ÔÇó Temperature: 38.6┬░C (101.5┬░F)
ÔÇó Heart rate: 108/min
ÔÇó Respiratory rate: 20/min
ÔÇó Blood pressure: 148/94 mm Hg
ÔÇó Oxygen saturation: 98% on room air
Provider's Note
0230: Client diagnosis: delirium secondary to a urinary tract infection and dehydration. Will transfer client to medical-surgical unit.
Laboratory Results
0230:
ÔÇó Serum toxicology screen: Alcohol: 60 mg/dL (80 to 200 mg/dL mild to moderate intoxication)
A nurse is caring for a 65-year-old male client in the emergency department (ED). Which of the following interventions should the nurse include in the client's care? Select the 3 interventions the nurse should implement.
Correct answer
A,D,E
Rationale
Maintaining a low stimulation environment, approaching slowly, and frequent reorientation address delirium symptoms by reducing agitation, building trust, and improving orientation, based on the clientÔÇÖs confused state.