Difficulty: Medium
Average Score: 64%
Simulated
Passage / Scenario
The nurse in the emergency department (ED) is caring for a 19-year-male client.Nurses' Notes
0210: Client brought to the ED via ambulance. The client was at a party and was ingesting an unknown substance. The client became paranoid, lashing out at other individuals, reported feeling 'very hot.' and subsequently collapsed on the ground.
0216: On assessment, the client was hyper-alert, vigilant, and paranoid. "I know you are out to get me!" Not oriented to situation. Pupils were 5 mm. Electrocardiogram shows sinus tachycardia with a rate of 126. Peripheral pulses 1+. Lung sounds were clear bilaterally. Abdomen was taut, normoactive bowel sounds in all quadrants. Vital signs: T 103┬░ F (39.7┬░ C), P 126, RR 22, BP 156/96, pulse oximetry reading 98% on room air.
0220: Physician notified for orders.
0239: Orders received. 22-gauge intravenous access was obtained in the left forearm.
0300: Vital signs reassessed: T 103┬░ F (39.7┬░ C), P 129, RR 24, BP 160/96, pulse oximetry reading 97% on room air.
0315: Called to the room by the nursing assistant. The client struck the nursing assistant with his closed fist. The client discontinued his IV access.
Complete the following sentence by using the lists of options. The nurse should first address this client's --------------as evidenced by the client's------------------------
Correct answer
B,E
Rationale
The nurse must immediately address this client's behavior because of its scalation that has led to the client assaulting the nursing assistant. It is the impression from the case study that this client is under the influence of a sympathomimetic, such as methamphetamine. Methamphetamine can cause a client to develop hyperarousal, leading to hypertension, tachycardia, and psychotic symptoms. Clients with acute methamphetamine intoxication may, without provocation, abruptly develop severe agitation and manifest extreme violence.Uncontrolled agitation results in hyperthermia, acidosis, rhabdomyolysis, and sudden cardiovascular collapse. Control of agitation and chemical sedation is a clinical priority.The nurse should immediately restrain the client and then notify the physician. In this extreme situation where the client has used physical violence, the nurse has the ability to restrain the client and then notify the physician. Once the client is restrained, the nurse should restart the vascular access device and administer prescribed diazepam to ameliorate the client's aggression further. The benzodiazepine (diazepam) will also lower his high pulse and blood pressure.