# Stage 5 — Take action. The response team arrives as the disoriented client starts climbing over the side rail after pulling off the monitoring leads. Arrange the primary nurse’s immediate bedside loop from first to last while assigned team tasks proceed in parallel.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372481&lang=en  
> language: en  
> subject: Chemical/Substance Use Disorder  
> category: PSI

## Question

Stage 5 — Take action. The response team arrives as the disoriented client starts climbing over the side rail after pulling off the monitoring leads. Arrange the primary nurse’s immediate bedside loop from first to last while assigned team tasks proceed in parallel.

Within minutes, reassess RASS or MINDS, respiration, vital signs, delirium, and safety; escalate for refractory agitation, oversedation, or a new competing cause

Once the immediate fall hazard is controlled and monitoring is connected, rapidly assess airway, breathing, circulation, bedside glucose, agitation, and IV patency

After the first benzodiazepine dose, give parenteral thiamine and ordered magnesium or fluid replacement while the team continues the differential evaluation

Stay with the client, stop the attempted fall, direct one-to-one observation, reconnect continuous oximetry and cardiac monitoring, and ready resuscitative equipment

Using the immediate assessment findings, administer the prescribed IV benzodiazepine under the delirium protocol while watching ventilation

## Explanation

Primary-nurse loop
With the team present: establish observation and monitoring → assess ABCs, glucose, and IV access → give protocol-guided benzodiazepine → deliver supportive therapy during parallel evaluation → reassess and escalate. This sequence describes one nurse’s closed loop, not a delay of concurrent team tasks.

## In-depth explanation

Step 1 — Secure the care environment
The agitated, disoriented client needs continuous observation and a monitored level of care before the primary nurse turns to individual tasks.

Step 2 — Assess before titration
Rapidly establish airway and respiratory status, circulation, glucose, oxygenation, agitation or sedation level, and usable IV access. These findings guide safe IV treatment.

Step 3 — Treat and support in parallel
Administer prescribed IV benzodiazepine toward light somnolence and watch ventilation. Thiamine, indicated electrolyte or fluid replacement, diagnostic work, and environmental care can proceed with assigned teammates rather than waiting serially.

Step 4 — Close the loop
Reassess with an objective scale plus respiratory, hemodynamic, cognitive, and safety findings. Escalate if agitation is refractory, sedation is excessive, or the trajectory suggests another cause.

NCLEX rule
In a team emergency, sequence the primary nurse’s closed loop while recognizing that other roles occur concurrently.

## Clinical scenario

Scenario (Stage 5 — Take action)
The response team has arrived. Sequence the primary nurse’s immediate bedside loop while other clinicians work in parallel.

Clinical judgment target
Use monitoring–assessment–treatment–reassessment without artificial whole-team delays.

## Key concepts

- **Closed-loop reassessment** — A cycle that measures response after treatment and triggers escalation for inadequate control or adverse effects.
- **Refractory withdrawal** — Withdrawal signs that remain inadequately controlled despite appropriate first-line treatment and require higher-level management.
- **Concurrent care** — Role-based tasks performed in parallel so monitoring, treatment, supportive care, and diagnostic evaluation do not wait on one another.

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