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

While all the outcomes are important in the overall care of a client with bipolar disorder, the safety of the client takes precedence, especially during the acute phase of the disorder. Bipolar disorder is characterized by mood swings that can include episodes of mania, which may involve risky behaviors or even thoughts of self-harm.
A. The client will remain safe throughout hospitalization: This is the priority outcome. Ensuring the safety of the client during hospitalization involves monitoring for any signs of self-harm or harm to others, managing any acute manic or depressive symptoms, and providing a secure environment.

B. The client will accomplish activities of daily living independently by discharge: While independence in activities of daily living is a valuable outcome, it may not be the immediate priority during the acute phase of bipolar disorder. Addressing safety and stabilization come first.

C. The client will use problem-solving to cope adequately after discharge: Coping skills are important for long-term management, but ensuring safety and stabilization during the hospitalization phase takes precedence. Coping skills can be addressed as part of the overall treatment plan.

D. The client will verbalize feelings during group sessions by discharge: Expression of feelings is an important aspect of mental health treatment, but safety and stabilization remain the priority, especially during the acute phase of bipolar disorder.

A. "The voices talk only at night when I'm trying to sleep." B. The voices say everyone is trying to kill me. C. I hear angels playing harps

Correct Answer is B

Explanation

A. "The voices talk only at night when I'm trying to sleep."

This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.

B. "The voices say everyone is trying to kill me."

This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.

C. "I hear angels playing harps."

This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.

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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 client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?

Correct Answer is A

Explanation

Which hallucination necessitates the nurse to implement safety measures? The patient says.

Correct Answer is B

Explanation

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