Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?
Social isolation RUT inability to relate to others
Risk for suicide R/T altered thought
Altered sensory perception RUT increased levels of anxiety
Risk for violence: directed toward others R/T suspicious thoughts
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.
B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.
C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.
D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.
Correct Answer is A
Explanation
Orientation: When a nurse asks a client to identify their name, date, residential address, and situation, they are assessing the client's orientation. Orientation refers to an individual's awareness of time, place, person, and situation.
B. Affect: Affect refers to the observable expression of emotions. It involves the client's emotional tone, such as being happy, sad, angry, or flat. It is not directly assessed by asking about personal information.
C. Perception: Perception involves the way individuals interpret and make sense of sensory information. Asking about personal information is more related to orientation than perception.
D. Mood: Mood refers to a more sustained emotional state. It is not directly assessed by asking for specific personal information about the current situation or location.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today