A 20-year-old college student who lives in

A 20-year-old college student who lives in a college dormitory on campus is transported to the emergency department (ED) for psychiatric evaluation. He has always been quiet, somewhat withdrawn, and had very few friends, but his roommate noticed that he has become more and more isolated and withdrawn in the past few months. He rarely attends any of his classes, but rather stays in his dormitory room most of the time, searching the Internet or playing video games. Last night, when the client’s roommate came back to their room late at night, the client was pretending to be asleep in the top bunk bed. When his roommate got into bed, the client jumped down from the top bunk holding a knife and threatened to kill him for stealing his things and turning people against him. The roommate managed to get out of the room unharmed and called the police. The client told the police that the FBI was after him and wanted to kill him. He also states that he had gone outside to smoke a cigarette earlier that evening and had heard someone telling him that his roommate had stolen his cell phone and was texting all of his contacts, turning them against him and that he needed to stop him. The police questioned the roommate, who said he did not take the client’s cell phone, and has not contacted any of the client’s family or friends. The roommate said he didn’t think he even had any friends anymore. When the police searched the client’s dormitory room, they found the client’s cell phone in his backpack. The police contacted emergency medical services (EMS) and the client was transported to the emergency department (ED). On arrival to the ED, the nurse receives the report about the events that led to the ED transport. Clinical Reasoning Plan- Complete on each patient 1. After completing your patient assessment and chart research, list all relevant patient data which is clinically significant: 2. Using the relevant patient data: Identify all current/potential patient issues/problems/concerns (All issues must have supporting data listed in #1 above. Rank the problem list in order of urgency and give your rationale for why 3. Considering the primary patient problem, create a goal for your patient: (Include date/time frame when goal should be completed) The patient will 4. Based on the priority problem, what are the priority nursing actions/interventions and provide the rationale for each. (Must have a minimum of 3 nursing interventions and you must have one assess, one do and one teach. Must include how frequently you will do your nursing actions.) Nursing Actions Rationales 1 Assess 2. Do 3. Teach 5. Evaluate patient’s response. Provide objective and/or subjective data. What additional interventions need to be considered? (Must list specific information to support your evaluation)

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