Case Scenario: A 20-year-old male being admitted to a state psychiatric hospital is accompanied by his brother. His clothing is rumpled and his overall hygiene is poor. He reports hearing voices.
He states, "I do not have time for this. I make and sell rare guitars. You've got to get out there and sell yourself, day and night, and that's what I do." The intake nurse notices that the client talks rapidly and with few breaks. "I don't need sleep. I need investors, people who believe in art, real art, you know? But you have to watch your back.
There are people who hate genius, and there are people who know what I've got and want to take it away from me. You have to fight for this." He eyes his brother angrily.
Vital signs indicate a BP of 142/90 with a resting heart rate of 102, and a skin turgor time of 4 seconds. He scores an 8 on the Altman Self-Rating Mania Scale. The health care provider assigns an initial diagnosis of Bipolar I disorder, complicated by a history of ADHD and migraines.
1. Identify the assessment findings that will require immediate follow-up by the nurse.
Select all that apply.
a. Resting heart rate of 102
b. History of migraines
c. History of childhood ADHD
d. Grandiosity
e. BP of 142/90
f. Sleep deprivation
g. Paranoia
h. Irresponsible financial choices
2. The nurse creates an initial nursing care plan for this client. Identify the nursing actions as Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-essential (not necessary) for the patient's care at this time.