The nurse has reviewed the Provider Orders from 2 weeks ago.

For each potential intervention, click to specify if the intervention is expected or unexpected for the adolescent. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A. "I should try to focus on pleasant images to help replace stressful and negative feelings I have.": This statement reflects the use of guided imagery, which promotes relaxation and emotional distraction, but it does not involve altering cognitive perceptions or beliefs about stress.

B. "I should reassess the situation and change my perceptions of stress by replacing irrational beliefs.": Cognitive reframing involves identifying and challenging distorted or irrational thoughts and replacing them with more balanced, realistic thinking. This statement demonstrates an understanding of altering cognitive patterns to manage stress effectively.

C. "I will tense my muscles for 8 seconds and then relax them to release the tension caused by my stress.": This describes progressive muscle relaxation, a physical technique to reduce somatic tension. While effective for stress management, it does not address thought patterns or cognitive appraisal.

D. "I will use my smartwatch to monitor my sleep and heart rate to assist me with gaining voluntary control over my stress.": Using a device for biofeedback helps monitor physiological responses and promote self-regulation, but it does not involve changing thought patterns, which is central to cognitive reframing.

Rationale for correct choices:

• Brief psychotic disorder: The client has sudden-onset psychotic symptoms, including paranoia, hallucinations, and disorganized behavior, triggered by recent stressors. Symptoms developed acutely over hours, with normal labs and no evidence of substance use or medical illness. These features align with brief psychotic disorder rather than delirium or anxiety.

• Engage with the client several times each day to establish trust: Frequent, consistent interactions help build rapport with a client experiencing acute psychosis. Establishing trust reduces anxiety, improves cooperation with assessment and treatment, and provides the nurse with opportunities to monitor mental status changes. Trust is critical for clients who are suspicious or fearful of others.

• Reduce external stimuli: Minimizing noise, light, and unnecessary activity can help decrease agitation, paranoia, and sensory overload, which are common in acute psychotic episodes. A calm environment supports stabilization of thought processes and emotional regulation during the brief psychotic episode.

• Fearfulness: Fear and hypervigilance are prominent during psychotic episodes, as the client may misinterpret environmental cues or perceive threats that are not present. Monitoring fearfulness allows the nurse to detect worsening agitation or paranoia and implement safety interventions promptly.

• Ability to care for self: Disheveled appearance and removal of clothing indicate impaired self-care during the episode. Monitoring the client’s ability to perform basic activities provides insight into functional recovery. Improvement suggests stabilization of thought processes and mood. Declining self-care may indicate relapse or worsening psychosis.

Rationale for incorrect choices:

• Ask the client if they have taken any medications, supplements, or illicit drugs: While substance use can mimic or trigger psychosis, the client’s blood alcohol and lab values are within normal limits, making substance-induced psychosis less likely. This action is not the immediate priority in managing the acute psychotic episode.

• Ask "Have you been sick recently?": Illness-related delirium or infection could cause altered mental status, but the client is afebrile and laboratory studies show no infection or metabolic disturbance. Physical illness does not appear to be contributing to the current psychotic presentation.

• Instruct the client to use self-talk: Although self-talk can help some clients manage anxiety, it is not the primary nursing intervention for acute psychosis. The client requires external support, trust-building, and environmental modifications before internal coping strategies can be effectively utilized.

• Anxiety: While anxiety may be present, the acute onset of hallucinations, paranoia, and disorganized behavior is more consistent with brief psychotic disorder. Anxiety alone does not explain the intensity or nature of the client’s symptoms.

• Delirium: Delirium typically develops over hours to days and is associated with fluctuating consciousness, attention deficits, and underlying medical causes such as infection or metabolic imbalance. This client is alert, oriented at baseline, and has normal labs, making delirium unlikely.

• Substance use disorder: The client’s lab results show no alcohol or metabolic abnormalities, and there is no evidence of recent substance use contributing to the psychotic episode. Although historical substance use could be relevant, it does not explain the current acute psychosis.

• Temperature: The client’s temperature is normal, and there are no signs of infection or inflammation. Monitoring temperature does not provide meaningful information about psychotic symptom progression. Mental status and behavior are more relevant indicators. Thus, this parameter is not a priority.

• Tremulousness: Tremors are commonly associated with substance withdrawal or anxiety, neither of which is evident. The client does not display motor agitation or shaking. Monitoring tremulousness would not help assess improvement in psychotic symptoms. It is not relevant to the current condition.

• Suicide risk: Although all psychiatric clients require general safety assessment, there is no indication of suicidal ideation or self-harm intent in this scenario. The client’s behavior centers on paranoia and fear rather than hopelessness or self-destructive thoughts.