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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B: "When using implanted contraceptive methods, condoms should also be used to protect against STDs."
Choice B rationale: While implanted contraceptive methods are highly effective in preventing unintended pregnancies, they do not provide protection against sexually transmitted diseases (STDs). Therefore, using condoms in conjunction with implanted contraceptives can enhance overall sexual health by reducing the risk of contracting or transmitting STDs. This statement highlights the nurse's understanding of the importance of comprehensive sexual health practices and the limitations of various contraceptive methods.
Choice A rationale: The use of petroleum-based lubricants with condoms can actually compromise their effectiveness. Petroleum-based lubricants can degrade latex condoms, increasing the likelihood of condom breakage or slippage, which in turn raises the risk of both pregnancy and STD transmission.
Choice C rationale: Condoms are indeed effective in preventing pregnancy, but their effectiveness can be enhanced by using them in conjunction with vaginal spermicides. Spermicides containing nonoxynol-9 can provide additional protection by inactivating or killing sperm, thus reducing the risk of pregnancy.
Choice D rationale: Ensuring a proper fit is crucial for a condom's effectiveness, but the statement only emphasizes the condom fitting snugly over the tip of the penis. For optimal protection, a condom should be unrolled to cover the entire erect penis, leaving a small empty space at the tip for semen collection. A condom that is not unrolled completely may be more likely to slip off or break during intercourse.
Correct Answer is C
Explanation
The correct answer is Choice C, the system is working properly.
Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained
Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops
Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped
Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed
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