On arrival in the emergency department, a patient who was in a motor vehicle accident is apprehensive, confused, and hypotensive. The patient has tachycardia, oliguria, and cool clammy skin. What should the nurse do first?
a. Cover patient with warm blankets.
b. Perform a rapid head-to-toe assessment.
c. Obtain patient's medical history from family.
d. Reorient the patient to person, place, and time.
ANS: B
The priority is to assess the patient in shock quickly, starting with the Cs: airway, breathing, circulation, and disability. A. Covering with blankets can occur after the initial rapid assessment is completed. C. The patient's medical history can be obtained at a later time. D. The patient can be reoriented at a later time.
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