A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication.
Which of the following interventions should the nurse include in the plan?

Mix the medication with the client's food items.

Speak in a neutral tone when addressing the client.

Limit the client's opportunities to socialize with others.

Rotate staff members caring for the client.

Answer and Explanation

The Correct Answer is B

B) Speak in a neutral tone when addressing the client.

When creating a plan of care for a client with paranoid personality disorder who refuses to take their medication, it's essential to approach the client in a way that fosters trust and reduces anxiety. Speaking in a neutral, non-confrontational, and non-threatening tone can help build rapport and facilitate communication with the client.

The other options are not appropriate interventions:

A) Mixing medication with the client's food without their consent can be seen as a breach of trust and may worsen the client's paranoia.

C) Limiting the client's opportunities to socialize with others can lead to increased isolation and potentially exacerbate the client's paranoid tendencies.

D) Rotating staff members caring for the client may also contribute to feelings of mistrust and may not be conducive to establishing a therapeutic nurse-client relationship. Consistency in care can be more helpful for individuals with paranoid personality disorder.

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Correct Answer is C

Explanation

The correct answer is C. Believes his bad behavior is causing his brother's death. This is an example of magical thinking, which is common among school-age children (6 to 12 years old). Magical thinking is the belief that one's thoughts or actions can influence events or outcomes that are beyond one's control. School-age children may feel guilty or responsible for their sibling's illness or death and may try to bargain or change their behavior to prevent it.

A. Sitting in high-Fowler's position during the feeding. B. A history of gastroesophageal reflux disease. C. A residual of 65 mL 1 hr postprandial. D. Receiving a high-osmolarity formula.

Correct Answer is B

Explanation

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

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A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

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A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication.
Which of the following interventions should the nurse include in the plan?