2330 – 22-year-old male client arrived at the emergency department (ED) with friends who were at a party and was observed snorting a white powder and started acting erratically.
The client is hyper-alert, agitated, and only oriented to place on assessment. The client started shouting at staff during the assessment and struck a nurse with his fist. The primary healthcare provider (PHCP) was immediately notified of this incident.
Temperature 98.0o F (37o C)
Pulse 110/minute
Respirations 16/minute
Blood Pressure 155/96 mm Hg
O2 saturation 96% on room air
➢ Complete the following sentences from the list of options
Based on the client assessment, the client is likely intoxicated with [heroin. / cocaine. / an opioid.] The nurse should immediately [restrain the client / obtain a prescription for an antihypertensive / obtain a urine drug screen] based on the client’s [blood pressure. / substance intoxication. / physical violence.]
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