A nurse is assisting with the care of a patient who is being admitted to an inpatient mental health care unit.

The client has a history of bipolar disorder.

Family members brought the client to the hospital after noticing that the client had become extremely agitated and anxious.

The family also reports that the client appears to be experiencing auditory hallucinations.

Upon data collection, the client speaks quickly and is unable to maintain attention or sit in one place for longer than a minute.

The client appears unkempt and reports that they cannot.

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.

Choice A rationale:

Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.

It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.

It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.

Choice B rationale:

Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.

This information can be used to develop a safety plan and to help the client manage their symptoms.

It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.

Choice C rationale:

Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.

It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.

It can also damage the therapeutic relationship between the nurse and the client.

Choice D rationale:

Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.

While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.

Choice A rationale:

I will contact my provider if I have difficulty urinating.

Chlorpromazine has anticholinergic effects, which can cause urinary retention. This means the medication can interfere with the normal function of the bladder, making it difficult to empty completely. Difficulty urinating can lead to bladder distention, urinary tract infections, and even kidney damage if left untreated.

It's crucial for the client to recognize this potential side effect and seek medical attention promptly if it occurs. Early intervention can help prevent complications and ensure proper bladder management.

By understanding this potential side effect and the importance of seeking help, the client demonstrates a grasp of the teaching provided.

Choice B rationale:

I might notice an increased frequency of my menstrual cycle.

Chlorpromazine does not typically affect menstrual frequency. While some antipsychotic medications can cause menstrual irregularities, chlorpromazine is not commonly associated with this effect.

If a client experiences changes in their menstrual cycle while taking chlorpromazine, it's important to discuss it with their healthcare provider to rule out other potential causes.

Choice C rationale:

These medications might cause breast tissue to atrophy.

Chlorpromazine is not known to cause breast atrophy. Breast atrophy, or shrinkage of breast tissue, can occur due to hormonal changes, aging, or certain medical conditions.

However, it's not a common side effect of chlorpromazine.

Choice D rationale:

I am at a decreased risk for infection while taking these medications.

Chlorpromazine does not decrease the risk of infection. In fact, it may slightly increase the risk of infection due to its potential to suppress the immune system.

It's essential for clients taking chlorpromazine to practice good hygiene and infection prevention measures to protect themselves from illness.