A nurse is caring for a client in an acute care setting.

Exhibits

Complete the following sentence by using the list of options.

The client is at risk for

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as evidenced by the client's 

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Potential Condition:

The client is most likely experiencing Brief Psychotic Disorder.

• Behavioral Clues: The client’s behavior, including running from EMS, shouting “No, you are not going to kill me,” and appearing disheveled with odd behaviors like mumbling and talking to themselves, is suggestive of a psychotic episode.
• Acquaintance Report: The acquaintance reports that the client has exhibited odd behaviors (e.g., talking when no one is present and being suspicious of everyone). This could be indicative of a pattern of behavior seen in brief psychotic disorder.
• Client History: The client mentions episodes of similar behavior starting at age 19, which is consistent with the onset of brief psychotic disorder in early adulthood.

Actions to Take:

• Engage with the client several times each day to establish trust:

In a psychotic state, it is important to create a trusting relationship. Building rapport helps the nurse understand the client’s perceptions and reality, while also reducing anxiety and providing reassurance. Engagement should be frequent and supportive to avoid alienating the client and to create a safe, comforting environment.

• Reduce external stimuli:

In brief psychotic disorder, external stimuli can overwhelm the client’s perception and exacerbate hallucinations or delusions. Reducing noise, unnecessary people, or overwhelming stimuli can help reduce agitation and improve the client’s ability to focus and function.

Parameters to Monitor:

• Suicide Risk:

Clients with psychotic disorders, particularly those experiencing delusions and hallucinations, are at an increased risk of self-harm or suicidal ideation. The nurse must assess the client's thoughts and feelings related to harm to themselves, especially given the potential disconnection from reality.

• Temperature:

Although the client's temperature is normal (37°C), psychotic episodes, particularly those that are intense or prolonged, can cause the body to become dysregulated. It's important to monitor the temperature as fever can indicate physical distress or complications (e.g., medication side effects).

Rationale for other conditions;

Substance Use Disorder: There is no evidence of current intoxication or withdrawal in the lab results (blood alcohol is 0 mg/dL), so substance use disorder is unlikely.

Delirium: The lab results and vital signs are within normal limits, and the client’s history does not suggest a medical issue that could cause delirium, such as infections or metabolic disturbances.

Anxiety: While anxiety could contribute to the client feeling “hot” or distressed, the client's psychotic behaviors (e.g., delusions, hallucinations) go beyond typical anxiety and suggest a more serious psychotic disorder.

A. Submerging feet in ice water may cause hypothermia and is not an appropriate method for cooling down.
B. Initiating seizure precautions is important due to the risk of seizures associated with elevated body temperature.
C. Acetaminophen is not effective for reducing body temperature in cases of hyperthermia and may mask important symptoms.
D. A thermal blanket can increase the temperature and should be avoided for hyperthermia management.