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Psychiatric Mental Health Nursing NCLEX RN Questions Part 52 Questions

Question 1 of 1

A client on a stretcher in the emergency department begins to thrash around, slap the sheets and yells, 'Get these bugs off of me.' She is disoriented and has a blood pressure of 189/75 and a pulse of 96. The friend who is with her says, 'She was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn't have any.' The nurse should do the following in which order from first to last?

Order the Items

Source Container

Obtain an order to place the client in restraints, if needed.
Implement constant observation.
Monitor vital signs every 15 minutes.
Administer haloperidol (Haldol) and lorazepam (Ativan) I.M. as ordered.
Remind the client that she is in the hospital and the nurse is with her.
Chart the client's response to the interventions.

Correct Answer: B, E, C, D, A, F

Rationale: The order is: 1) Constant observation for safety (
B). 2) Remind client of hospital setting (E). 3) Monitor vital signs (
C). 4) Administer medications (
D). 5) Obtain restraint order if needed (
A). 6) Chart response (F). Safety and orientation are prioritized, followed by treatment and documentation.

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Question 3 of 1

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