A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this clients safety?
Note escalating behaviors and intervene immediately
interpret attempts at communication
Assess for medication noncompliance
Assess triggers for bizarre, inappropriate behaviors
The Correct Answer is A
A. Note escalating behaviors and intervene immediately:
This option prioritizes the client's safety by addressing escalating behaviors promptly. Bizarre behaviors, neologisms, and thought insertion may indicate a severe episode of psychosis, and timely intervention is crucial to prevent harm to the client or others.
B. Interpret attempts at communication:
While understanding and interpreting communication are important, in a situation with escalating behaviors and potential safety concerns, immediate intervention takes precedence. Communication interpretation can follow once the safety of the client has been ensured.
C. Assess for medication noncompliance:
Medication noncompliance can contribute to exacerbation of symptoms, but in an acute situation where safety is a concern, addressing immediate behaviors takes precedence. Medication assessment can be done in the context of a more comprehensive assessment after the immediate safety concerns have been addressed.
D. Assess triggers for bizarre, inappropriate behaviors:
Identifying triggers is important for understanding the underlying causes of the behavior, but in the context of escalating behaviors and potential safety issues, immediate intervention to de-escalate the situation is the priority. Triggers can be explored once the immediate safety concerns are addressed.
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Related Questions
Correct Answer is D
Explanation
A. Social isolation R/T inability to relate to others
While social isolation may be a concern for individuals with paranoid personality disorder, the immediate safety risk associated with the disorder is more related to the potential for violence. Therefore, addressing the risk of violence takes precedence.
B. Risk for suicide R/T altered thought:
Paranoid personality disorder is not typically associated with a high risk of suicide. Individuals with this disorder are more likely to pose a risk to others due to their suspicious thoughts and mistrust. Suicide risk assessments are crucial but may not be the top priority in this specific case.
C. Altered sensory perception R/T increased levels of anxiety:
Paranoid personality disorder does involve heightened levels of anxiety, but altered sensory perception is not a primary characteristic of the disorder. Addressing anxiety is important, but the potential for violence toward others is a more immediate concern.
D. Risk for violence: directed toward others R/T suspicious thoughts:
This is the most appropriate priority. Individuals with paranoid personality disorder may have intense mistrust and suspicion, leading to the potential for aggressive or violent behavior directed toward others. Prioritizing safety and preventing harm to others is crucial in the care of clients with this disorder.
Correct Answer is C
Explanation
A. Psychiatrist: Psychiatrists focus primarily on medical and pharmacological interventions for mental illnesses. While they play a crucial role in diagnosing and treating mental health conditions, they typically do not have the expertise in housing assistance or social services.
B. Behavioral therapist: Behavioral therapists focus on psychotherapeutic interventions to address and modify behavior. They are not typically involved in addressing social determinants of health, such as housing.
C. Social worker: Social workers are specifically trained to address social issues, including housing. They work with clients to assess their social needs, connect them with resources, and advocate for their well-being. In this case, a social worker would be instrumental in helping the client find housing resources and support.
D. Psychologist: Psychologists primarily focus on psychological assessments, therapy, and interventions. Like psychiatrists, their expertise is more centered around mental health treatment rather than addressing the social determinants of health such as housing.
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