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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use touch to calm the client during periods of anxiety:
Individuals with paranoid schizophrenia may have heightened sensitivity to touch, and it can potentially exacerbate their anxiety or paranoia. This intervention may not be appropriate as it could escalate the client's distress.
B. Check the client's mouth after the client takes medication:
This is the best choice. People with paranoid schizophrenia may be prone to hoarding or pocketing medications. Checking the client's mouth ensures that the medication has been swallowed, promoting medication adherence and preventing potential harm.
C. Rotate the staff assignments for this client:
Consistency in caregivers is generally preferred for clients with schizophrenia to build trust and a therapeutic relationship. Constantly changing staff assignments can lead to increased anxiety and mistrust.
D. Assign an assistive personnel to feed the client at meal times:
While assistance with feeding may be needed, assigning an assistive personnel without direct supervision for a client with paranoid schizophrenia may not be the best approach. It's important to ensure the client's safety and monitor their behavior during meals.

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.
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