Skip to ContentGo to accessibility pageKeyboard shortcuts menu
OpenStax Logo

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.



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    
Rationale: The diagnosis has not been confirmed yet; therefore, haloperidol would not be administered. Urodynamic study (UDS) would be conducted to help ascertain a diagnosis. Following release from restraints, the client would be under close observation to prevent further outbursts of aggression. There is no need to administer insulin or bandage the head of the client. It would not be recommended to allow the mother to sit with the client as this might trigger the client to be aggressive again. A comprehensive metabolic panel (CMP) would be conducted to help ascertain a diagnosis.

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    

This book may not be used in the training of large language models or otherwise be ingested into large language models or generative AI offerings without OpenStax's permission.

Want to cite, share, or modify this book? This book uses the Creative Commons Attribution License and you must attribute OpenStax.

Attribution information
  • If you are redistributing all or part of this book in a print format, then you must include on every physical page the following attribution:
    Access for free at
  • If you are redistributing all or part of this book in a digital format, then you must include on every digital page view the following attribution:
    Access for free at
Citation information

© Jun 25, 2024 OpenStax. Textbook content produced by OpenStax is licensed under a Creative Commons Attribution License . The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the Creative Commons license and may not be reproduced without the prior and express written consent of Rice University.