The Nurse Has Just Been Notified That a Client Is

Multiple Choice

The nurse has just been notified that a client is to be admitted from the emergency department (ED) with a diagnosis of alcohol intoxication. The ED nurse says they have been unable to obtain much history because of the client's lethargic state. Which action is an appropriate intervention by the nurse?

A) Approach the client with caution when obtaining vital signs and shift assessments.
B) Place the client in a room farthest from the nurse's station so as not to disturb other clients.
C) Place the client in four-point restraints as a protective measure.
D) Post an armed security person at the client's door.