Client is agitated and diaphoretic. Oriented to person and place only. Pupils equal and reactive.

Client is agitated and diaphoretic. Oriented to person and place only. Pupils equal and reactive. Client reports dry mouth and tooth pain. CV: Client reports feeling frequent heart palpitations. Regular rate and rhythm noted at time of assessment, no murmurs or peripheral edema. Respiratory: regular rate and rhythm. Abdomen: soft and diffusely tender. Client reports severe nausea. Bowel sounds present in all 4 quadrants. MS: grips weak and equal, able to move all extremities equally. Severe tremor noted to bilateral hands. Client reports hearing a voice telling the client to get up and leave. The nurse is reviewing the client’s assessment. Click to highlight the findings that will require immediate follow up. Client is agitated and diaphoretic . Oriented to person and place only . Pupils equal and reactive. Client reports tooth pain . CV: Client reports feeling frequent heart palpitations . Regular rate and rhythm noted at time of assessment, no murmurs or peripheral edema. Respiratory: regular rate and rhythm. Abdomen: soft and diffusely tender . Client reports severe nausea . Bowel sounds present in all 4 quadrants. MS: grips weak and equal , able to move all extremities equally. Severe tremor noted to bilateral hands. Client reports hearing a voice telling the client to get up and leave.

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