Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?
Provide personal space to respect the clients boundaries
Maintain continual eye contact throughout the interview
Provide neon lights and soft music
use therapeutic touch to increase trust and rapport
The Correct Answer is A
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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Related Questions
Correct Answer is B
Explanation
A. These programs help clients correct distorted body image:
While behavioral programs may incorporate components related to body image, the primary focus is often on addressing and modifying specific behaviors associated with eating disorders, such as binge eating, purging, or restrictive eating.
B. These programs help clients manage uncontrollable behaviors:
This is the correct answer. Behavior modification programs aim to address and modify specific behaviors that contribute to eating disorders. This can include establishing healthier eating patterns, reducing binge-purge cycles, and promoting more adaptive coping strategies.
C. These programs allow clients to maintain control:
While the concept of control is relevant to eating disorders, behavior modification programs are designed to help clients gain control over maladaptive behaviors and establish healthier patterns. It's not about maintaining control over the disorder itself.
D. These programs address underlying client anger:
While emotions, including anger, may play a role in eating disorders, behavior modification programs are more focused on targeting and modifying specific behaviors rather than addressing underlying emotions directly. Emotional aspects may be addressed through additional therapeutic interventions
Correct Answer is B
Explanation
A. "The voices talk only at night when I'm trying to sleep."
This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.
B. "The voices say everyone is trying to kill me."
This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.
C. "I hear angels playing harps."
This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.
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