A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship.
Which of the following statements should the nurse make during this phase?

Choice A rationale:

A client who received a Mantoux test 48 hr ago and has an induration does not require immediate follow-up care. An induration at the injection site indicates a positive reaction, but further evaluation and management are necessary, not urgent.

Choice B rationale:

A client taking warfarin with an INR of 1.8 requires follow-up care. The normal range for INR in a client taking warfarin is usually 2.0 to 3.0. An INR of 1.8 suggests inadequate anticoagulation, putting the client at risk of thromboembolic events. Dose adjustment or other interventions are needed to bring the INR within the therapeutic range.

Choice C rationale:

A client scheduled for a colonoscopy and taking sodium phosphate does not necessarily require immediate follow-up care. However, sodium phosphate can cause electrolyte imbalances, so monitoring for any signs of electrolyte disturbances is essential, but it does not mandate urgent intervention.

Choice D rationale:

A client taking bumetanide with a potassium level of 3.6 mEq/L requires follow-up care. The normal range for potassium is typically 3.5 to 5.0 mEq/L. A potassium level below the normal range (hypokalemia) can lead to cardiac arrhythmias and muscle weakness. The client may need potassium supplements or dietary adjustments to correct the imbalance.

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.