The nurse is caring for a client with schizotypal personality disorder who was experiencing transient psychotic episodes that led to admission. The client was unkempt and appeared not to have bathed for quite some time. When planning the care of this client, which will be the focus of the nursing interventions? Select all that apply.

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

Choice A reason: This statement shows that the client is willing to ground their decisions in reality, which is a key step in managing paranoid personality disorder.

Choice B reason: Trusting others is important, but it does not indicate that the client has learned to validate their ideas before acting.

Choice C reason: Differentiating true suspicions is part of managing the disorder, but it does not demonstrate an understanding of the need to validate ideas with others.

Choice D reason: Understanding the origins of paranoid thinking is insightful, but it does not show that the client has learned to validate their ideas before taking action.