A nurse is caring for a client in an emergency department. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress
Explanation & Rationale
Potential Condition Brief Psychotic Disorder: The client presents with acute onset of paranoia, hallucinations, disorganized behavior, and suspiciousness, which are characteristic of brief psychotic disorder (a sudden onset of psychotic symptoms lasting more than a day but less than a month, often triggered by stress). The absence of intoxication (blood alcohol: 0 mg/dL) and normal laboratory results rules out substance-related causes or metabolic imbalances. The client acknowledges stress as a trigger and has a history of odd behaviors, paranoia, and disorganized thinking, which further supports a psychotic disorder. Actions to Take Engage with the client several times each day to establish trust: Clients with psychosis often feel fearful and paranoid; frequent, calm interactions help build trust and reduce distress. Reduce external stimuli: Minimizing noise, bright lights, and overwhelming environments can help decrease agitation, paranoia, and sensory overload, which may worsen psychotic symptoms. Parameters to Monitor Suicide risk: Clients experiencing psychosis may have suicidal ideation due to delusions, distress, or hopelessness. Close monitoring is essential for safety. Ability to care for self: Psychotic episodes can impair daily functioning, including hygiene, eating, and medication adherence. Monitoring this helps assess recovery progress.