A nurse is caring for a client who has schizophrenia.

Exhibits

The nurse is reviewing the client's medical record.

Select the "3" findings that require immediate follow-up by the nurse.

A. Stage 2 (moderate): In this stage of alcohol withdrawal, symptoms may include increased anxiety, tremors, and elevated vital signs, but hallucinations and severe disorientation are not typically present. The client's current condition exceeds the expectations of moderate withdrawal, indicating a more severe level.
B. Stage 1 (mild): Mild withdrawal symptoms are generally characterized by anxiety, insomnia, and mild tremors. The presence of hallucinations, significant changes in vital signs, and severe disorientation suggests that the client is experiencing more than just mild withdrawal symptoms.
C. Stage 3 (severe): Severe alcohol withdrawal is characterized by the presence of hallucinations, severe agitation, confusion, and autonomic instability, as indicated by the client's elevated blood pressure and heart rate. The client’s experience of seeing spiders and disorientation about their location indicates severe withdrawal, which may lead to complications like delirium tremens if not properly managed.
D. The client's manifestations indicate a psychotic disorder instead of alcohol withdrawal: While hallucinations can be indicative of a psychotic disorder, the context of recent alcohol use and the accompanying withdrawal symptoms strongly suggest that the client is experiencing severe alcohol withdrawal rather than a separate psychotic disorder.

A. Splitting: This mechanism is commonly seen in clients with borderline personality disorder. It involves viewing people or situations in black-and-white terms, categorizing them as all good or all bad. This can create division among the healthcare team, as team members may be viewed differently by the client depending on their current mood or interactions, leading to conflicts and confusion within the team.
B. Regression: This defense mechanism involves reverting to behaviors of an earlier developmental stage. While it may occur in borderline personality disorder, it does not typically create division among healthcare team members like splitting does.
C. Reaction formation: In this case, individuals behave in a way that is opposite to their true feelings. Although it can occur in various contexts, it is not as commonly associated with creating division within the healthcare team.
D. Denial: This mechanism involves refusing to accept reality or facts. While present in borderline personality disorder, it does not specifically lead to division among team members in the same way.