Nokea
The following scenario applies to the next 1 items
The emergency department nurse is caring for a 22-year-old with altered mental status
Item 1 of 1
Admission Notes
2330 – 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically.
The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident.
Vital Signs
• Temperature 98.0o F (37o C)
• Pulse 110/minute
• Respirations 16/minute
• Blood Pressure 155/96 mm Hg
• O2 saturation 96% on room air
Complete the following sentences from the list of options.. Based on the client assessment, the client is likely intoxicated with ___ the nurse should immediately ___ based on the client's ___
Correct Answer: B, C, F
Rationale: The client's agitation, hyper-alertness, and violence suggest cocaine intoxication. Immediate restraint ensures safety, and violence justifies this action.