Question

A nurse is assessing a client with bizarre and aggressive behavior in the emergency department. Upon questioning, the client's partner discloses that the client had been smoking PCP. While in the emergency department, the client continues to exhibit signs of PCP-induced psychosis and has required physical restraints. What nursing outcome should the nurse prioritize in the care of this client?

A. The client will be physically safe and without injury.
B. The client will demonstrate appropriate social skills.
C. The client will establish a balance of rest, sleep, and activity.
D. The client will verbalize acceptance of responsibility for the behavior.

Answer 1

The nurse should prioritize the client's physical safety and prevention of injury in a case of PCP-induced psychosis. Other objectives like social skills or acceptance of responsibility are secondary to immediate safety.

Step-by-step explanation:

In the scenario of a client exhibiting PCP-induced psychosis and aggressive behavior, the immediate nursing outcome that should be prioritized is ensuring the client's physical safety and the prevention of injury. Given the altered mental state and potential for harm due to PCP effects, the nursing staff should focus on maintaining a safe environment for both the client and others around.

Options such as B, demonstrating appropriate social skills, and D, verbalizing acceptance of responsibility, although important in the longer-term care plan, are not immediate priorities. Similarly, establishing a balance of rest, sleep, and activity (Option C) is secondary to ensuring immediate safety. The administration of neuroleptic drugs may be considered to manage symptoms such as agitation, restlessness, and potentially harmful behavior. Over time, these medications can help in reducing hallucinations, delusions, and incoherent thinking.

Ultimately, the primary goal is to stabilize the client to prevent injury and create a foundation for further treatment of the psychosis and underlying substance abuse issues.