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History of present illness: 45-year-old male was admitted involuntarily to the mental health unit after threatening a social worker. Client was belligerent at the time of admission; the client’s significant other was present and able to provide some history. Client lives at home with his partner and their two children. The significant other reports the client eats a regular diet, smokes 1/2 pack per day, and drinks approximately 10-12 beers per day. Client is unemployed after being laid off about two years ago. When asked about a history of violence in the home, the significant other avoided the question. The client was given lorazepam 4 mg IV for sedation in the emergency department with no noted effect. Medical History: unknown; has not been seen by a medical provider in many years. Home medications: none The nurse is identifying potential interventions that may help the client. Which intervention(s) should the nurse expect to perform? Select all that apply. Administer lorazepam IV. Administer IV fluids. Prevent aspiration. Protect the client’s airway. Place pads on the client’s side rails. Initiate venous thromboembolism (VTE) prophylaxis.
SCIENCE
HEALTH SCIENCE
NURSING

 
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