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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Group therapy is an economical way of providing therapy to many clients concurrently.": While this statement may be true, it does not directly address the client's concerns or provide information about the voluntary nature of group participation.

B. "Group therapy is optional. You can go if you find the topic helpful and interesting.": This is the correct answer. Acknowledging the client's autonomy and providing information about the voluntary aspect of group therapy respects the client's preferences and promotes a collaborative therapeutic relationship.

C. "Group therapy is mandatory. All clients must attend.": This statement is more authoritarian and does not take into account the individual needs and preferences of the client. It is important to involve clients in decisions about their treatment whenever possible.

D. "The purpose of group therapy is to learn and practice new coping skills.": While this statement provides information about the purpose of group therapy, it does not directly address the client's question about the optional nature of attendance.

A. Implement the client's behavioral modification plan B. Document the size and location of the cuts C. Administer a tetanus antitoxin. D. inspect the cuts for debris

Correct Answer is D

Explanation

A. Implement the client's behavioral modification plan:

While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.

B. Document the size and location of the cuts:

Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.

C. Administer a tetanus antitoxin:

Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.

D. Inspect the cuts for debris:

This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.

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Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly admitted client asks. "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing response?

Correct Answer is B

Explanation

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is discussing bias issues in mental health with a newly licensed nurse. Which of the following statements should the nurse include in the discussion?

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid: benztropine (Cogentin), 1 mg prn: and zolpidem (Ambien). 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether