A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations.
What is the priority action?

Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.

Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.

Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.

Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.

Choice A is wrong because relationship and evaluation are not techniques of physical assessment.

Relationship refers to the rapport and trust established between the nurse and the patient.

Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.

Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.

They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.

Choice D is wrong because color is not a technique of physical assessment.

Color is an aspect of inspection, which is one of the techniques of physical assessment.

Place the call bell in reach and respond promptly when activated.

This is a safety measure that allows the client to communicate their needs and request assistance when needed. The nurse should also check the drain for patency, observe for bright red bloody drainage, and maintain an aseptic technique when emptying the drain.

Choice A is wrong because advising the client to stay in bed and only get up with assistance may limit their mobility and increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumonia.

The client should be encouraged to ambulate as soon as possible after surgery, with appropriate assistance and precautions.

Choice C is wrong because maintaining the bed at working height for convenience when doing post-op vital signs may increase the risk of falls or injury if the client tries to get out of bed without assistance.

The bed should be lowered to a safe position and locked when not in use.

Choice D is wrong because keeping the lights off to encourage the client to rest and recuperate may impair the client’s vision and orientation, and increase the risk of falls or injury if they try to get out of bed without assistance.

The client should have adequate lighting in their room and be oriented to their surroundings.

Choice E is wrong because attaching the drain to wall suction and keeping the tubing pinned to the client’s gown may interfere with the function of the drain and cause tension or kinking of the tubing. The drain should be attached to gravity drainage and secured loosely to prevent accidental dislodgment.