A 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse
His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse's first action should be to:
1. Take the client's vital signs
2. Restrain the client to prevent injury
3. Obtain a prn order for a psychotropic medication
4. Ask the client for information about his medications
ANS: 1
The disorder may be due to an infection or underlying organic disorder, so vital signs are of first priority. Restraint is not indicated at this time, nor is medication. Option 4 is incorrect because the client is confused and disoriented.
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