A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

Rationale:

A. Irrigate the wound using a 10 mL syringe: A 10 mL syringe does not provide enough volume or control for effective wound irrigation. Typically, a 30 to 60 mL syringe with an appropriate catheter or tip is used to deliver a steady, low-pressure stream.

B. Cleanse the insertion site of the drain using a circular motion toward the center: Cleansing should be performed from the center outward in circular motions to avoid dragging contaminants toward the wound or drain site. Cleaning toward the center increases the risk of infection.

C. Cleanse the wound starting at the bottom and moving upward: Wound cleansing should be performed from the least contaminated area to the most contaminated — usually from top to bottom or from the incision line outward. Cleaning from bottom to top can introduce bacteria to cleaner areas.

D. Irrigate the wound with a low-pressure flow of solution: Using a low-pressure irrigation helps to flush out debris and reduce bacterial load without damaging healthy tissue or forcing contaminants deeper into the wound. It is the recommended method for safe and effective wound cleansing.

Rationale:

A. Rotate staff members caring for the client: Clients with paranoid personality disorder often struggle with trust and may become more suspicious if care is inconsistent. Assigning consistent staff helps build therapeutic rapport and minimizes perceived threats.

B. Mix the medication with the client’s food items: Covertly administering medications violates the client’s autonomy and can worsen paranoia if discovered. Open, honest communication is essential when working with clients who have paranoid thoughts.

C. Speak in a neutral tone when addressing the client: A neutral, calm, and nonjudgmental tone reduces perceived hostility or manipulation. It supports the development of trust and helps avoid triggering defensive or suspicious behaviors.

D. Limit the client’s opportunities to socialize with others: Social interaction should not be restricted unless it poses a safety risk. Encouraging appropriate socialization may help reduce isolation and reinforce reality, even if the client has difficulty with interpersonal relationships.