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. 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 C
Explanation
A. Psychiatrist: Psychiatrists focus primarily on medical and pharmacological interventions for mental illnesses. While they play a crucial role in diagnosing and treating mental health conditions, they typically do not have the expertise in housing assistance or social services.
B. Behavioral therapist: Behavioral therapists focus on psychotherapeutic interventions to address and modify behavior. They are not typically involved in addressing social determinants of health, such as housing.
C. Social worker: Social workers are specifically trained to address social issues, including housing. They work with clients to assess their social needs, connect them with resources, and advocate for their well-being. In this case, a social worker would be instrumental in helping the client find housing resources and support.
D. Psychologist: Psychologists primarily focus on psychological assessments, therapy, and interventions. Like psychiatrists, their expertise is more centered around mental health treatment rather than addressing the social determinants of health such as housing.
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