0210: Client brought to the ED via ambulance. The client was at a party and was ingesting an unknown substance. The client became paranoid, lashing out at other individuals, reported feeling 'very hot.' and subsequently collapsed on the ground.
0216: On assessment, the client was hyper-alert, vigilant, and paranoid. "I know you are out to get me!" Not oriented to situation. Pupils were 5 mm. Electrocardiogram shows sinus tachycardia with a rate of 126. Peripheral pulses 1+. Lung sounds were clear bilaterally. Abdomen was taut, normoactive bowel sounds in all quadrants. Vital signs: T 103° F (39.7° C), P 126, RR 22, BP 156/96, pulse oximetry reading 98% on room air.
0220: Physician notified for orders.
0239: Orders received. 22-gauge intravenous access was obtained in the left forearm.
0300: Vital signs reassessed: T 103° F (39.7° C), P 129, RR 24, BP 160/96, pulse oximetry reading 97% on room air.
0315: Called to the room by the nursing assistant. The client struck the nursing assistant with his closed fist. The client discontinued his IV access.
➢ Complete the following sentence by using the lists of options.
The nurse should ****first**** address this client's [temperature / behavior / blood pressure / fluid status] as evidenced by the client's [electrocardiogram. / physical violence. / vital signs. / peripheral pulses.]
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