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. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.

B. "Why are you overreacting to the issue?"

This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.

C. "You should bring this to the attention of your treatment team."

While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.

D. "I'll talk to Peter and present your concerns."

This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.

A. "Group therapy is an economical way of providing therapy to many clients concurrently." B. "Group therapy is optional. You can go if you find the topic helpful and interesting." C. Group therapy is mandatory. All clients must attend." D. "The purpose of group therapy is to learn and practice new coping skills.

Correct Answer is B

Explanation

A. "Group therapy is an economical way of providing therapy to many clients concurrently.": While this statement may be true, it does not directly address the client's concerns or provide information about the voluntary nature of group participation.

B. "Group therapy is optional. You can go if you find the topic helpful and interesting.": This is the correct answer. Acknowledging the client's autonomy and providing information about the voluntary aspect of group therapy respects the client's preferences and promotes a collaborative therapeutic relationship.

C. "Group therapy is mandatory. All clients must attend.": This statement is more authoritarian and does not take into account the individual needs and preferences of the client. It is important to involve clients in decisions about their treatment whenever possible.

D. "The purpose of group therapy is to learn and practice new coping skills.": While this statement provides information about the purpose of group therapy, it does not directly address the client's question about the optional nature of attendance.

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