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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Falling asleep in the chair and refusing to eat lunch is not indicative of tardive dyskinesia (TD). TD is characterized by involuntary movements, not by changes in sleep patterns or appetite.
B. Correct. Grimacing and lip smacking are characteristic movements associated with tardive dyskinesia. TD is a side effect of long-term use of typical antipsychotic medications, and it involves involuntary, repetitive movements, often involving the face and mouth.
C. Incorrect. Excessive salivation and drooling are not specific to tardive dyskinesia. These symptoms may occur due to various reasons, and TD is primarily associated with abnormal, involuntary movements.
D. Incorrect. Experiencing muscle rigidity and tremors is more characteristic of other side effects or conditions, such as extrapyramidal symptoms, but it is not specific to tardive dyskinesia. TD typically involves repetitive, involuntary movements rather than tremors.
Correct Answer is B
Explanation
A. "I will take Lithobid on an empty stomach": This statement is incorrect. Lithobid is usually taken with meals or right after meals to minimize gastrointestinal side effects. Taking it on an empty stomach may lead to increased side effects.
B. "I will maintain normal salt intake": This statement is correct. Lithium levels in the blood can be influenced by sodium levels. Maintaining a consistent and normal salt intake is important for the proper functioning of lithium in the body. Both low and high sodium levels can affect lithium levels.
C. "I will consume more fluids": This statement is generally correct. Adequate fluid intake is important to prevent dehydration, as lithium is excreted by the kidneys. However, it should be balanced, and excessive fluid intake should be avoided to prevent lithium toxicity.
D. "I will limit my intake of fluids daily": This statement is incorrect. While fluid intake should be monitored and maintained at a reasonable level, restricting fluids too much can lead to dehydration and an increased risk of lithium toxicity.
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