A 21-year-old male is found outside of a gas station and according to bystanders, he was constantly talking for hours straight about the end of the world and the conspiracy of the government to control our minds. The patient appears to not have taken a shower in a long time; his hair is matted, his skin is dirty, he has a strong body odor and his nails are long with dirt under them. The patient is quoting the bible and asking everyone who enters the room if God has saved them yet. The nurse is assessing this patient and is asked if she could get Jesus a glass of water.
Ask the patient if they can see Jesus and if Jesus is telling the patient to do something.
Safety first! Assessing the reality of a patient is more important than re-orienting them.
Re-orienting them happens after the nurse knows the patient doesn’t think Jesus is saying to kill everyone
Critical Thinking Check
Bloom's Taxonomy: Application
The patient states, “Don’t you know who Jesus is? He will kill you if he wanted to. Don’t upset Jesus and get him a glass of water.” What should the nurse do at this point?
Inform the patient that the only people you can see are the patient and yourself.
Do not say you see the patient’s hallucination or validate the patient’s idea by getting ‘Jesus’ a glass of water.
Try to divert the conversation back to the assessment and avoid getting stuck talking about the delusion.
The patient cooperates and is answering the nurse’s questions. Vital signs are stable and the patient tells the nurse that he has never been treated for any mental health problems before. He also tells the nurse that he is running away from home because people keep breaking into his apartment to laugh at him and steal his peanut butter and all of his writings because they will lead people to the secrets the government has been keeping. The nurse asks about medications the patient takes at home and the patient replies, “I don’t take that poison.”
All of a sudden the patient starts to question the nurse and accuse the nurse of trying to trick the patient into taking poison and make him conform to the societal norms that the government wants us to do. The patient becomes very anxious and is staring at the door.
The nurse should make positive statements and then move the focus of the conversation such as, “I will not poison you, I promise. You seem nervous, do you want to take a break for a few minutes?”
Allowing the patient a break can help interrupt the concerning thoughts the patient was having
After a break the patient decides that they would like to have a pen and paper to write down any thoughts that comes to mind while speaking. The nurse continues the assessment and looks down to see the patient drawing a picture of the nurse with a pencil stabbed into the neck.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is the most important thing for the nurse to do at this time?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 