0855: Notified by client's daughter that the client had been speaking normally but suddenly began mumbling, became visibly confused, and was noted to have difficulty speaking clearly. Client evaluated at bedside. Client found sitting upright in bed, alert but disoriented. Speech is slurred, minimal, and largely incoherent. Client is unable to reliably follow simple verbal commands. Unable to name common objects or repeat simple phrases. Right upper extremity grip strength was noted to be weaker compared to earlier in the shift.
0904: Vital signs obtained. 142/84 mm Hg, 105 bpm, irregular, 18/min, 95% on room air, 36.7°C (98.0°F). Capillary blood glucose 72 mg/dL (4 mmol/L) [70-110 mg/dL; 4-6 mmol/L].
- alcohol use disorder
- hyperlipidemia
- atrial fibrillation
- hypertension
- diabetes mellitus (type two)
The nurse is reviewing the client's change of condition and is preparing to act.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client’s progress.
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