A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior.
Which of the following interventions should the nurse recommend to be included in the plan of care?

Choice A rationale:

Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.

Choice B rationale:

Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.

Choice D rationale:

Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.

Choice C rationale:

Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:

Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.

Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.

Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.

Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.

Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.

Choice A rationale:

While group activities can be beneficial for some clients with bipolar disorder, they may not be appropriate during a manic phase. This is because group settings can be overstimulating and overwhelming for individuals experiencing mania. The increased activity and social interaction can exacerbate symptoms such as racing thoughts, pressured speech, and impulsivity.

It's crucial to prioritize calming activities and minimize external stimuli during manic episodes.

Choice C rationale:

Providing a stimulating environment is not recommended for clients in the manic phase of bipolar disorder. A stimulating environment can worsen symptoms of mania, such as:

Increased energy and activity levels

Racing thoughts

Impulsivity

Distractibility

Risk-taking behavior

Irritability

Aggression

Decreased need for sleep Grandiose thinking

Poor judgment

Hypersexuality

A calm and structured environment is more conducive to managing manic symptoms.

Choice D rationale:

Scheduling daily seclusion times is not a standard intervention for clients in the manic phase of bipolar disorder. Seclusion is a restrictive intervention that should only be used as a last resort when a client is at risk of harming themselves or others. It's essential to explore less restrictive alternatives for managing manic symptoms, such as medication, therapy, and environmental modifications.