A nurse on a mental health unit is assisting with the care of a client.
The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.
Ask the provider for a PRN prescription for restraints.
Administer diazepam when the client exhibits anxiousness.
Place the client in a room near the nurse's station.
Determine if the client is experiencing command hallucinations.
Establish clear limits for expected behaviors.
Correct Answer : B,C,D,E
A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.
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Related Questions
Correct Answer is C
Explanation
A. Preschooler: Schizophrenia is not typically diagnosed in preschoolers. Early childhood development issues may occur, but the onset of schizophrenia usually occurs later in life.
B. School-age: While some symptoms may begin to appear during the school-age years, schizophrenia is not commonly diagnosed at this age. Diagnosis is more likely to occur in later developmental stages.
C. Young adulthood: Schizophrenia is most commonly diagnosed in young adulthood, typically between the late teens and early 30s. This age range is when the onset of psychotic symptoms usually occurs, making it crucial for staff to understand the timing of diagnosis for effective intervention.
D. Older adulthood: While late-onset schizophrenia can occur, it is much less common. Most cases are diagnosed in young adulthood, and the prevalence decreases significantly in older adulthood. Understanding the typical age of diagnosis helps healthcare professionals identify and support individuals at risk.
Correct Answer is D
Explanation
A. Lack of feelings of remorse: This finding is more characteristic of antisocial personality disorder rather than paranoid personality disorder. Individuals with paranoid personality disorder may feel justified in their suspicions but do not typically lack remorse for their actions.
B. Inflated sense of self: An inflated sense of self is associated with narcissistic personality disorder. Individuals with paranoid personality disorder may have self-doubt but often feel their beliefs and perceptions are valid.
C. Requiring frequent reassurance from others: This behavior is more typical of dependent personality disorder. Individuals with paranoid personality disorder are generally distrustful of others and may not seek reassurance due to their suspicious nature.
D. Suspiciousness of others: This is a key characteristic of paranoid personality disorder. Individuals with this disorder often exhibit a pervasive distrust and suspiciousness of others, interpreting their motives as malevolent. This finding is expected when assessing a client with paranoid personality disorder.
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