Difficulty: Medium
Average Score: 76%
Simulated
During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client├óÔé¼Ôäós upper and lower extremities. Which intervention is most important for the nurse to implement on admission?
Correct answer
C
Rationale
Establishing a baseline neurologic status is critical for monitoring changes and determining the cause of the acute confusion, which could be due to hypoxia, electrolyte imbalance, or neurological injury. Administering medication without a clear cause could mask symptoms. A sitter may be used for safety, but identifying the underlying problem is more urgent. Assessing oxygen saturation is important but is just one component of the full neurological assessment.