A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

A. Enables the nurse to assign the appropriate Axis I diagnosis: Nurses typically do not assign Axis I diagnoses. Diagnosing mental health conditions is typically the responsibility of psychiatrists, psychologists, or other licensed mental health professionals. Nurses, however, play a crucial role in gathering information to contribute to the overall assessment process.

B. Enables the nurse to prescribe the appropriate medications: Nurses do not prescribe medications; that is the responsibility of physicians, nurse practitioners, or other prescribers. However, gathering client information is essential for providing accurate information to the prescriber, assisting in medication management, and monitoring for side effects.

C. Enables the nurse to modify behaviors related to personality disorders: While nurses can assist in the management of behaviors related to mental health conditions, the primary purpose of gathering client information is not to modify behaviors related to personality disorders. It is more about understanding the client's needs and tailoring care accordingly.

D. Enables the nurse to make sound clinical judgments and plan appropriate care: This is the correct answer. Gathering client information is a fundamental step in the nursing assessment process. It provides the necessary data for the nurse to make informed clinical judgments, identify health problems, and plan appropriate care interventions. It allows the nurse to understand the client's unique needs, preferences, and potential risks, leading to individualized and effective care planning.

A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.

B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.

C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.

D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.