A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.
Assess vital signs
Ask the client about medications
Ask the client what he recalls from the accident
Prepare the client for mechanical ventilation
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Identify the underlying cause. This is correct because delirium is a reversible condition that is often caused by an underlying medical problem, such as infection, medication, or dehydration.
Identifying and treating the cause can help resolve the delirium and prevent further complications.
Tell the client that hallucinations are not real. This is incorrect because it can increase the client's anxiety and confusion. The nurse should acknowledge the client's feelings and perceptions, but not reinforce or argue with them.
Speak slowly and clearly. This is incorrect because it is not the best first action. While speaking slowly and clearly can help communicate with the client, it does not address the root cause of the delirium.
Request the assistance of physical therapy. This is incorrect because it is not relevant to the question. Physical therapy may be helpful for some clients with delirium, but it is not a priority intervention.
Correct Answer is A
No explanation
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