A nurse is contributing to the plan of care for a client who has paranoid schizophrenia. Which of the following interventions should the nurse recommend to be included in the plan of care?
Assume an upbeat friendly attitude when talking with client.
Allow patient to uncover/unwrap items on the food tray.
Use touch to calm the client during periods of anxiety.
Rotate the client’s staff assignments daily.
The Correct Answer is B
Choice A reason: An overly friendly attitude may increase suspicion in a client with paranoia. A calm, neutral approach is more therapeutic.
Choice B reason: Allowing the client to unwrap food items helps reduce paranoia about tampering or poisoning. This intervention promotes trust and reduces anxiety.
Choice C reason: Using touch can be misinterpreted and increase paranoia or agitation. Physical contact should be avoided unless necessary for safety.
Choice D reason: Rotating staff frequently can increase mistrust. Consistency in caregivers helps build rapport and reduce paranoia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Asking if the client feels pressured to do things they do not want to do helps identify coercion or abuse. This is a direct way to assess safety and autonomy in the relationship.
Choice B reason: Fear of a previous partner can indicate ongoing threats, stalking, or unresolved trauma. This question helps assess risk of continued abuse even after the relationship has ended.
Choice C reason: Asking if the client feels safe in their relationship is a broad but essential screening question. It allows the client to express concerns about current safety and potential abuse.
Choice D reason: Asking about a caretaker threatening harm is more relevant to elder abuse or dependent care situations rather than intimate partner violence. While important in other contexts, it does not directly assess intimate partner safety.
Correct Answer is A
Explanation
Choice A reason: Denial is a defense mechanism where the client refuses to acknowledge the reality of a traumatic event. Sitting calmly and claiming to be "fine" despite visible injuries reflects denial, as the client is minimizing or rejecting the seriousness of the situation.
Choice B reason: Undoing involves attempting to reverse or "make up for" a behavior or thought, often through symbolic actions. This is not evident in the client’s response.
Choice C reason: Displacement occurs when emotions are redirected from the original source to a safer target. The client is not redirecting anger or fear but instead denying the trauma.
Choice D reason: Projection involves attributing one’s own feelings or thoughts to others. The client is not projecting but denying their own reality.
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