A nurse on a mental health unit is assisting with the care of a client.

Exhibits

The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.

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.

A. Interpersonal therapy: This type of therapy focuses on improving interpersonal relationships and social functioning, which is beneficial for clients with avoidant personality disorder. It helps individuals address their fears of rejection and develop healthier social interactions, making it a suitable therapeutic approach for this client.
B. Antidepressant medications: While antidepressants may be prescribed to help alleviate symptoms of anxiety or depression often associated with avoidant personality disorder, they do not specifically target the underlying interpersonal issues. Medication alone is not considered a primary treatment for this personality disorder.
C. Dialectical behavior therapy: Dialectical behavior therapy (DBT) is primarily designed for individuals with borderline personality disorder and focuses on emotion regulation and interpersonal effectiveness. While it may benefit some clients, it is not the first-line therapy for avoidant personality disorder.
D. Antipsychotic medications: Antipsychotic medications are generally not indicated for avoidant personality disorder, as the disorder does not typically involve psychotic symptoms. These medications are more appropriate for conditions like schizophrenia or severe mood disorders and do not address the core features of avoidant personality disorder.