When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Challenge the patient at all times and remen in control of the situation

Provide clear and straight forward communication

Hold person accountability for their actions

Remain consistent

Avoid being too nice or friendly.

Answer and Explanation

Correct Answer : B,C,D

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

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Correct Answer is C

Explanation

A. Concrete thinking: Concrete thinking refers to a style of thinking that is focused on immediate and literal aspects of information. The patient's statement involves more than concrete thinking; it includes an irrational belief about the consequences of contagious bacteria, indicating a distorted perception of reality.

B. Agitation: Agitation refers to a state of restlessness or increased activity. The patient's statement does not necessarily reflect agitation but rather a specific paranoid belief about the consequences of bacteria exposure.

C. Paranoia: This is the correct answer. Paranoia involves irrational thoughts and fears of being harmed or persecuted by others. The patient's belief that contagious bacteria are everywhere and will lead to being locked up with other infected people is indicative of paranoid ideation.

D. Poverty of thought: Poverty of thought is characterized by a lack of meaningful or detailed thought content. The patient's statement is not an example of poverty of thought; rather, it involves specific and elaborate content related to a paranoid belief.

A. Provide personal space to respect the clients boundaries B. Maintain continual eye contact throughout the interview C. Provide neon lights and soft music D. use therapeutic touch to increase trust and rapport

Correct Answer is A

Explanation

A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.

B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.

C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.

D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.

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When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other Infected people. Which problem is evident?

Correct Answer is C

Explanation

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Correct Answer is A

Explanation

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