The nurse is caring for a client in the emergency department (ED) who complains of chest pain and reports that people were following her
She states, "I can't see them but they are talking about grabbing me." While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. Which is the priority when continuing the assessment for this client?
1. Spiritual affiliations.
2. Dietary preferences and habits.
3. Review of systems.
4. Focused psychosocial interview.
Correct Answer: 4
The woman is exhibiting bizarre behavior and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. A spiritual assessment and dietary preferences are important, but the psychosocial interview would be a priority given the behaviors exhibited. The physical examination is conducted after the interviewing is complete.
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The client presents to the labor and delivery unit stating that her water broke 2 hours ago. Barring any abnormalities, how often would the nurse expect to take the client's temperature?
1. Every hour 2. Every 2 hours 3. Every 4 hours 4. Every shift