While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech
The vital signs are BP 160/88 mmHg, apical pulse 102 beats per minute, respiratory rate 26 per minute. Which responses by the nurse are appropriate in this situation?
Select all that apply.
1. "I'm going to take your temperature now."
2. "Have you ever experienced chest pain?"
3. "Are you feeling any anxiety right now?"
4. "Are you experiencing any pain at this time?"
5. "Have you ever been diagnosed with hypothyroidism?"
Correct Answer: 2, 3, 4
The client's actions may indicate that the client is experiencing pain. The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. The client's actions are also consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. It will be appropriate to assess the client's temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. The client's vital signs and actions are more likely associated with hyperthyroidism.
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