Use the case study information provided to answer this question.
After reviewing the 0200 vital signs and nurse’s notes, what should the nurse do first?
Intro to Case
The LPN is taking care of a 43-year-old male client on the medical-surgical floor. He was recently admitted with alcohol withdrawal symptoms.
Nurse’s Notes
2200: Admission assessment completed by RN. Client states he has not had an alcoholic beverage in 10 hours and “doesn’t feel right.” He states he is trying to quit, but doesn’t know if he will be able to without medical treatment. He has been a heavy drinker since he was 14 years old. Client’s hands are visibly shaking and forehead is sweating.
0200: Client’s bed alarm is going off and nurse called into room because he believes he is covered in spiders. He is screaming and running all around the room. Client pulled his peripheral IV out and there is blood pouring from his forearm. Nurse reoriented client to place and informs client there are no spiders crawling on him at this time. Client is very agitated and will not stay in the bed. Client agreed to let nurse take his vital signs while standing up.
History and Physical
Vital Signs
Call the client’s wife to see if she can come to sit with him.
Attempt to calm the client and place them on oxygen via nasal cannula.
Place mittens on the client and shut the door until the doctor calls back.
Give the client his PRN blood pressure medication.
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