A nurse on an inpatient mental health unit is caring for a client.

Exhibits

The nurse is discussing the assessment findings on day 3 of admission during the 1900 change of-shift report. For each finding, specify whether the finding indicates potential improvement in or worsening of the client’s condition.

Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.

Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.

Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.

Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.

Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood

Indicates potential worsening a. Giving away car b. Condition of skin on right hand

Choice A: Giving away car

This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.

Choice B: Hygiene

The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.

Choice C: Food intake

The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.

Choice D: Condition of skin on right hand

The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.

Choice E: Rapid change in mood

The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.