Unfolding Case Study
a, b, d, f, h
Rationale: The client has cues that could indicate electrolyte imbalance, head trauma, substance use or mental health disorder, such as confusion, delirium, pacing and muttering, agitation, and suspicion. Also, the client has exhibited a change in personality and is exhibiting abnormal behavior with reported audio hallucinations. The client’s blood pressure and heart rate, while still within normal limits, are considered high for this client given the circumstances.
The client is oriented to time, place, and person, which is a normal finding. Likewise, respirations, temperature, and oxygen are all within normal limits.
| Cue | Electrolyte Imbalance | Head Trauma | Mental Illness |
| Confusion | X | X | X |
| Agitation | X | X | X |
| Hallucinations | X | ||
| Altered personality | X | X | |
| Suspicion | X | ||
| Altered vitals | X | X | X |
Rationale: Electrolyte imbalance manifests with confusion, agitation, and altered vital signs.
Head trauma manifests with confusion, agitation, altered personality, and altered vital signs.
Mental illness manifests with confusion, agitation, hallucinations of some form, altered personality, and suspicion.
d
Rationale: Safety is always a key priority in caring for clients who are disturbed, particularly ensuring the safety of others, including family, visitors, other clients, and staff.
| Actions | Recommended | Not Recommended | Irrelevant |
| Administer haloperidol | X | ||
| Urodynamic study (UDS) | X | ||
| Close observation | X | ||
| Administer insulin | X | ||
| Bandage head of client | X | ||
| Let the mother sit with client | X | ||
| Comprehensive metabolic panel (CMP) | X |
The nurse knows that the client will be prescribed risperidone (Risperdal) that may result in side effects such as blurred vision, constipation, and dry mouth. The client will be evaluated for improvement in his condition as evidenced by the client engaging in therapeutic modalities and complying with his medication.
Rationale: Given his symptoms and behavior, the client will be prescribed an antipsychotic medication such as risperidone (Risperdal), which may have side effects such as blurred vision, constipation, and dry mouth. The client will demonstrate improvement in their condition when they engage in therapeutic modalities and comply with medication.
| Behavior | Effective | Ineffective | Irrelevant |
| Takes his medications | X | ||
| Watches television | X | ||
| Complains that people are following him | X | ||
| Is isolated and talking to himself | X | ||
| Talks in group therapy sessions | X | ||
| Talks to his mother on the telephone | X | ||
| Can talk about what might trigger a psychotic episode | X |