A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
Start intravenous fluids.
Administer diazepam.
Obtain a medical history.
Raise the side rails of the bed.
The Correct Answer is D
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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
No explanation
Correct Answer is D
Explanation
A. Discuss self-defense techniques with the client: Incorrect
While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.
B. Give the client a bed bath prior to physical examination: Incorrect
In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.
C. Inform the client photographs of injuries are required for a police report: Correct
Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.
D. Ask the client to describe the situation: Correct
It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.
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