hard · NCLEX-RN psychosocial
A client, Case ID: PSY-99-01, was admitted 48 hours ago for a fractured femur and has a history of chronic alcohol use. The nurse notes the client is now agitated, with hand tremors and a BP of 162/98 mm Hg. Which interventions are appropriate to include in the immediate plan of care? Select all that apply.
- Initiate seizure precautions including suction and oxygen at the bedside.
- Administer prescribed diazepam based on the Clinical Institute Withdrawal Assessment (CIWA-Ar) score.
- Apply soft wrist restraints to prevent the client from removing the IV line.
- Place the client in a well-lit, high-stimulation room to maintain orientation.
- Provide high-caloric oral glucose supplements before administering thiamine.
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