Exhibits

The nurse reviews the entries in the medical record.

The nurse is preparing the client for a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

A. A temperature of 37.4° C (99.3° F) is within the normal range during labor and does not require intervention.
B. A fetal heart rate (FHR) baseline of 170/min is elevated, which could indicate fetal distress, requiring further evaluation and intervention.
C. Early decelerations in the FHR are common during contractions and are not typically a cause for concern.
D. Contractions lasting 80 seconds are within the normal range for active labor and do not require reporting unless they become too frequent or intense.

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.