A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

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.

• This is a concerning finding because the adult child reports cognitive and physical decline in the client, which could indicate severe memory loss, cognitive impairment, or potentially dementia or other mental health conditions such as depression or suicidal ideation.
• Significant weight loss and decreased appetite in an older adult can indicate serious conditions, including malnutrition, depression, or potentially serious medical conditions such as cancer or other chronic diseases. Immediate follow-up is needed to assess the cause of the weight loss, evaluate the client’s nutritional status, and address any underlying health concerns.
• This statement is concerning because it suggests the client may be experiencing depression or suicidal ideation. Older adults are particularly vulnerable to depression, and this expression of worthlessness is a red flag that the client could be at risk for suicide. The nurse shouldimmediately assess the client’s mental health status, ask about thoughts of self-harm, and potentially initiate a psychiatric evaluation.