1014 Medical History: Depression, paranoid personality disorder,
0830 hyperipidemia
Family history:
« Mother diagnosed with schizophrenia at age 28
« Fatheris not i olved in client’s lfe, estranged from family when client
6 years old, history of paranoid personality disorde
« Client victim of adverse childhood events, physical abuse by father as
young child
« Currently homeless, stating, I stay on fiends’ couches sometimes.
Why do you want to know?
Home Medications:
« Simvastatin
+ Escitalopram
« Paroxetine
, Nursing | Other
NURSING ASSESSMENT & NOTES.
1114 Neuro/Cognitive: Alert and oriented x 4
0900
Cardiovascular: $1 and S2 heart sounds. Heart rate within normal limits,
regular rate, and thythm.
Respiratory: Lung sounds clear bilaterally. Breathing is tachypneic.
Psychosocial: The client is pacing the room and visibly upset. The client
frequently taps his foot and tries to see what the nurse is charting on the
computer. The client reports feeling anxious.
1114 Nursing Note: Nurse completing screening questions with client. When
1015 inquiring about thoughts of suicidal/homicidal ideation, client states, “who
asks those kinds of questions? Are you planning to hurt me? No, | would
never hurt anyane elser” Client refuses to contract for safety of himself.
Question 1 Correct Mark 3334 out of 3 .34
Before answering this question, review the client’s health information in
the EHR. Complete the sentences using the drop-down choices.
The nurse knows paranoid personality is a pattem of mistrust ¢
v and suspiciousness ¢ v of others. The client misinterprets
others' motives as malicious ¢ v
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