Question

A nurse in an emergency department is caring for a client.

Physical Examination:
1200: Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids.
Vital Signs:
1200: Temperature 38.4°C (101.1°F), Pulse rate 126/min, Respirations 28/min, BP 92/54 mm Hg, Oxygen saturation 93%
Nurses' Notes:
1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, 'I'm going home.' Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left.
1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on the situation.
Complete the following sentence by using the list of options.
The nurse should first __________ followed by ___________.
a) Address the client's confusion, reorient the client
b) Secure the IV line, call for additional help
c) Notify the family, administer IV fluids
d) Call for additional help, reorient the client

Answer 1

First, the nurse should call for additional help to ensure safety and assistance, then focus on reorienting the disoriented client.

Step-by-step explanation:

The nurse should first call for additional help followed by reorienting the client. Given the client's disorientation and confusion, securing safety and additional assistance takes priority. Once help is secured, the nurse can then focus on reorienting the client to the time, place, and circumstances, which may help reduce the client's confusion and improve compliance with treatment.