A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Rationale for Correct Choices

• Brief psychotic disorder: The client presents with sudden onset of delusions (“You are not going to kill me”), disorganized behavior, and paranoia following recent stressors such as job loss and financial strain. The symptoms have lasted less than one month, which aligns with the diagnostic criteria for brief psychotic disorder.

• Engage with the client several times each day to establish trust: Building a therapeutic relationship is essential to reduce fear, suspicion, and isolation in a client experiencing psychosis. Frequent, calm interactions promote a sense of safety and help the client gradually differentiate reality from delusional thoughts.

• Reduce external stimuli: Minimizing environmental noise, bright lights, and crowding helps prevent sensory overload, which can worsen hallucinations or paranoia. A quiet, structured environment supports emotional stability and reduces the likelihood of agitation or relapse during the acute phase of psychosis.

• Suicide risk: Clients experiencing psychosis are at elevated risk for self-harm, especially when frightened by delusions or experiencing feelings of hopelessness. Continuous monitoring for suicidal ideation or intent is critical to ensure safety and allow prompt intervention.

• Ability to care for self: Psychotic symptoms can impair basic functioning, including hygiene, nutrition, and sleep. Ongoing assessment of self-care ability guides the nurse in planning supportive measures and determining when the client can safely resume independent activities.

Rationale for Incorrect Choices

• Delirium: Delirium typically presents with acute confusion, fluctuating levels of consciousness, and is often linked to medical causes such as infection or metabolic imbalance. The client’s stable vital signs and normal laboratory results rule out physiological causes, making delirium unlikely.

• Substance use disorder: Although the client reports smoking, there is no evidence of intoxication or withdrawal. The blood alcohol level is zero, and the behavior aligns more closely with a psychotic episode than substance-related symptoms.

• Anxiety: Anxiety can cause restlessness and worry but does not explain the client’s hallucinations, delusions, or disorganized thoughts. The presence of paranoia and impaired reality testing distinguishes psychosis from anxiety disorders.

• Teach the client to use self-talk: This strategy is more appropriate for clients with anxiety or mild stress reactions. During acute psychosis, the client’s perception of reality is distorted, and cognitive techniques such as self-talk would not be effective or safe.

• Ask, "What kind of drugs have you been taking?" While assessing for substance use is important, the question is not a priority once laboratory results rule out intoxication. The client’s presentation is more consistent with a primary psychiatric disorder rather than drug-induced behavior.

• Ask, "Have you been sick recently?" This question may help identify medical causes of delirium or infection, but in this case, vital signs and labs are normal, indicating that a physical illness is not contributing to the symptoms.

• Tremulousness: Tremors are associated with withdrawal syndromes such as alcohol or benzodiazepine withdrawal, not psychotic disorders. Monitoring for tremulousness would not provide relevant data on the client’s recovery.

• Fearfulness: Although the client may appear fearful, this is a symptom rather than a measurable parameter to track progress. Monitoring safety and functionality provides more objective indicators of improvement.

• Temperature: The client’s temperature is normal, and there is no evidence of infection or metabolic disorder. Temperature monitoring is not a priority in managing psychosis unless medication-induced hyperthermia or medical complications develop.

Rationale:
A. A client who reports frequent and painful urination: This client likely has a urinary tract infection, which requires assessment and treatment but is not immediately life-threatening.

B. A client who reports left arm pain following a fall: Pain from trauma requires evaluation, but unless there are signs of impaired circulation or severe injury, it is lower priority than potential neurologic emergencies.

C. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension may indicate a hypertensive crisis or impending stroke. Immediate assessment is required to prevent life-threatening complications, making this the highest priority.

D. A client who has heart failure and received a diuretic 30 min ago: Monitoring is necessary to assess diuretic effects, but this client is stable and does not require immediate intervention compared with the client at risk for hypertensive emergency.