ATI RN
ATI Mental Health Exam II Questions
Extract:
Question 1 of 5
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?
Correct Answer: D
Rationale: The correct answer is D: Raise the side rails of the bed. This action should be taken first to ensure the safety of the older adult client experiencing delirium tremens, as they may be at risk for falls or injury. By raising the side rails, the nurse can prevent the client from accidentally falling out of bed or wandering off unsupervised. This immediate safety measure takes precedence over other actions such as starting intravenous fluids, administering diazepam, or obtaining a medical history, which can be addressed once the client's safety is ensured. Additionally, raising the side rails does not involve potential risks associated with medication administration or invasive procedures.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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