Delusional thinking of a grandiose nature

Mr. Joshua is a 55-year-old male with a long history of delusional thinking of a grandiose nature. He was brought to the ED on an emergency petition because he was found by the police to be argumentative with the salesman of a car dealership over the topic of buying a new car. This client proclaimed angrily that he had a special relationship with a movie star that he claimed sent him there to purchase a new BMW 2021, SUV. When the dealer called for a financial background check, the client’s credit score was below 200. It was determined upon investigation that this client is homeless and unemployed. He has been sleeping in a nylon tent sitting on the sidewalk over a subway train vent that provides warm steam. This client was noted unkept with his hair and body. He also had a foul odor coming from his clothing which was dirty and that he wore in 4 layers. This client became extremely angry with the salesman that told him that he did not meet the criteria through the credit bureau to be able to purchase a car.  Joshua also could not provide an address for the salesman except for the corner of Light and Holliday Street. He was noted invading the personal space of the sales manager that asked that he him leave his car dealership.   This client was hyperverbal with rapid pressured speech. He was constantly in motion noted swinging his arms and hands in the air as he spoke.

The policeman said that this client seemed to require medication to slow himself down and decrease his threatening behavior towards others. He was allowed to use the phone at the dealership to call the famous movie star he claimed to know personally to verify to sales that he would help Joshua pay for the BMW.  This client is angry in affect and laughs loudly at times. Joshua is labile in mood with elation at times. He has purchased a color television from a local store but cannot pick it up because he has no place to plug it up and watch it.   This client has an angry affect at times and mood swings. Has been unemployed for 1 year.

Page 2 Case Situation- Joshua

Has been sleeping on the sidewalk over a ventilator vent from the subway in a tent downtown. He is disheveled, wearing layers of clothing for the past 2 years. He eats his meals at a soup kitchen. He has family but claims that he cannot stay with them because they say that he is to hyper, loud, not sleeping and has unpredictable periods of anger. This client reports that the children of his family are frightened to be around him. Joshua reports not taking his drugs or seeking treatment for 3-4 months due to his complaints of the side-effects of the drugs prescribed.     He complains of the drugs cause him to have sexual problems and weight gain. This client has been living on the sidewalk or under a bridge. This client is pacing rapidly around the store . He was asked not to keep going into the store asking people for money and becoming angry when they did not give any to him. Joshua was seen in the Ed due to his aggressiveness, hyperactivity, and paranoid grandiose ideations  and was involuntarily  admitted to the inpatient behavioral health unit. Upon admission to the floor this client proceeded to hit the technician and was administered Haldol 10 mg. IM. The client agreed to stay in his room for an hour to let the medication help to decrease his agitation and anxiety.   After an hour, this client was at the nurses’ station complaining of thickness of his tongue, some drooling, and his eyes were going up in his head. The client was unable to make the eyes to stay own. All that could be seen was the whites of his eyes .   He was certified by the ED doctors after medical clearance. Joshua was given the diagnosis of Bipolar Disorder, Mania


1.     Identify what the client is experiencing.

2.     Define what was going on with his eyes and his tongue.

3.     What causes reactions like that?

4.     Use the SBAR format to provide a report to the Nurse Practitioner on duty.

Page 3 Case Situation-Joshua

5.    What medication might be ordered for this client?

6.    Would this client need to receive medication in po. or IM. form?

7.    What might this client’s psychiatric diagnosis be?

8.    Might this client be described as neurotic or psychotic, explain!

9.    Provide a Nursing Diagnosis?

10. What kind side effects is this client experiencing.   Name and define the classification of the drugs that

would be given (refer to Chapter 4 of Townsend and Morgan 10th. Edition.

Please fill in the Axis according to the DSM 5

Axis I_________________________________

Axis II ________________________________

Axis III ________________________________

Axis IV ________________________________

Axis V ________________________________

>>>Use a SBAR form to document what you would report to the oncoming RN about this client’s experience the shift.


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