medium · NCLEX-RN Management of Care

A nurse witnesses a collapse at a grocery store. The individual is awake but appears confused and has a strong smell of alcohol. The nurse offers to perform a blood glucose check with the individual's own meter. The individual shouts, 'Get away from me, I don't want your help!'

How should the nurse proceed?

  1. Remain nearby to ensure safety while respecting the individual's right to refuse
  2. Call the individual's emergency contact to get permission to treat
  3. Perform the check anyway because the smell of alcohol suggests impaired judgment
  4. Ask a store security guard to restrain the individual so the assessment can be finished

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