A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

Use clear, calm statements and a confident physical stance

Provide objective evidence that violence is unwarranted.

Empathize with the clients paranoid perceptions.

initially restrain the client to maintain safety

Answer and Explanation

The Correct Answer is A

A. Use clear, calm statements and a confident physical stance:

This is the most appropriate choice. Clear and calm communication, along with a confident physical stance, can help to de-escalate the situation. It demonstrates assertiveness and can potentially prevent further escalation of violence.

B. Provide objective evidence that violence is unwarranted:

While providing objective evidence may be helpful in some situations, individuals with paranoid personality disorder may not respond well to attempts to prove that their perceptions are unwarranted. It could potentially escalate the situation.

C. Empathize with the client's paranoid perceptions:

While empathy is important in communication, empathizing with paranoid perceptions in a way that validates or reinforces them may not be the best approach. It could inadvertently validate the client's distorted thoughts and potentially escalate the situation.

D. Initially restrain the client to maintain safety:

Physical restraint should be a last resort and used only when the safety of the client or others is at immediate risk. Initial restraint can escalate aggression and may not be the most appropriate intervention in the early stages of a violent episode.

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Correct Answer is A

Explanation

A. To emphasize that the client is capable of consuming food without purging: This is the correct purpose of the intervention. By recalling a time when the client was able to consume food without engaging in purging behaviors, the nurse aims to highlight the client's capability to eat without resorting to unhealthy practices.

B. To incorporate specific foods into the meal plan to reflect pleasant memories: While incorporating pleasant memories into the meal plan can be a positive aspect of treatment, the primary purpose of the intervention described is to focus on the client's ability to eat without purging.

C. To assist the client to become more compliant with the treatment plan: While promoting compliance with the treatment plan is important, the specific intervention described is more about exploring the client's past experiences with eating without purging to reinforce the possibility of achieving healthier eating habits.

D. To gain additional information about the progression of the disease process: The intervention is not primarily aimed at gaining information about the progression of the disease process. Instead, it is focused on emphasizing the client's capacity to eat without engaging in purging behaviors.

A. Use touch to calm the client during periods of anxiety B. Check the clients mouth after the client takes medication C. Rotate the staff assignments for this client D. Assign an assistive personnel to feed the client at meat times

Correct Answer is B

Explanation

A. Use touch to calm the client during periods of anxiety:

Individuals with paranoid schizophrenia may have heightened sensitivity to touch, and it can potentially exacerbate their anxiety or paranoia. This intervention may not be appropriate as it could escalate the client's distress.

B. Check the client's mouth after the client takes medication:

This is the best choice. People with paranoid schizophrenia may be prone to hoarding or pocketing medications. Checking the client's mouth ensures that the medication has been swallowed, promoting medication adherence and preventing potential harm.

C. Rotate the staff assignments for this client:

Consistency in caregivers is generally preferred for clients with schizophrenia to build trust and a therapeutic relationship. Constantly changing staff assignments can lead to increased anxiety and mistrust.

D. Assign an assistive personnel to feed the client at meal times:

While assistance with feeding may be needed, assigning an assistive personnel without direct supervision for a client with paranoid schizophrenia may not be the best approach. It's important to ensure the client's safety and monitor their behavior during meals.

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A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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