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 D

Explanation

A. "Why do you think you are being lied about and poisoned?": This question may come across as confrontational or challenging, potentially increasing the client's anxiety or defensiveness. It's important to acknowledge the client's feelings rather than questioning their beliefs directly.

B. "You are mistaken. Nobody is lying about you or trying to poison you.": This statement is dismissive and may cause the client to feel invalidated. It is crucial to acknowledge the client's feelings and experiences, even if they are not based on reality.

C. "Who is lying about you and trying to poison you?": This question may unintentionally reinforce the delusional thinking by suggesting that someone is indeed lying or trying to poison the client. It's essential to avoid validating or encouraging the delusional content.

D. "You seem to be having very frightening thoughts.": This statement acknowledges the client's emotions without directly challenging the delusional content. It shows empathy and creates an open and non-confrontational environment, allowing the client to express their feelings and experiences.

A. To emphasize that the client is capable of consuming food without purging B. To incorporate specific foods into the meal plan to reflect pleasant memories C. To assist the client to become more compliant with the treatment plan D. To gain additional information about the progression of the disease process

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.

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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

A nurse is caring for a client who has schizophrenia and tells the nurse. "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse working with a client diagnosed with bulimia nervosa ask the client to recall a time in life when food could be consumed without purging Which is the purpose of this nursing intervention?

Correct Answer is A

Explanation

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