Exhibits

A nurse in an emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

A. Splitting behavior: Splitting, or viewing people as all good or all bad, is characteristic of borderline personality disorder rather than histrionic personality disorder. It reflects difficulty integrating positive and negative aspects of self and others.

B. Emotional lability: Clients with histrionic personality disorder often display rapidly shifting emotions, exaggerated expression of feelings, and attention-seeking behaviors. Emotional lability is a hallmark feature, making this an expected manifestation.

C. Self-centered behavior: While clients with histrionic personality disorder may seek attention, overt self-centeredness and grandiosity are more characteristic of narcissistic personality disorder rather than histrionic traits.

D. Suspicious of others: Suspiciousness and distrust are typical of paranoid personality disorder. Clients with histrionic personality disorder are generally sociable and seek approval rather than displaying pervasive mistrust.

A. Irrigate a client's incision: Wound irrigation is a sterile procedure that requires nursing judgment and skill to prevent infection and assess wound healing. This task should not be delegated to assistive personnel.

B. Determine a client's pain level: Assessing pain requires clinical judgment to interpret subjective and objective findings and evaluate the need for interventions. This responsibility remains with the licensed nurse.

C. Insert a nasogastric tube: Insertion of a nasogastric tube is an invasive procedure that requires nursing knowledge and technical skill to ensure proper placement and prevent complications. It is not within the scope of assistive personnel.

D. Provide postmortem care: Postmortem care is a noninvasive task that involves preparing the body, performing hygiene, and maintaining dignity. It falls within the scope of practice for assistive personnel and can be safely delegated.