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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Favoring clients over others based upon their mental health diagnosis is not an indication of bias: This statement is incorrect. Favoring or discriminating against clients based on their mental health diagnosis is a clear indication of bias, and it is an issue that the nursing profession aims to address.

B. Displaying basis & conscious art: It seems like there might be a typo in this option. Assuming it means "Displaying bias, conscious or not," this could be a relevant point in discussing unconscious biases that individuals may hold, impacting their interactions with clients.

C. There is a negative stigmatization for mental lives: This is the correct answer. This statement acknowledges the existence of negative stigmatization associated with mental health. Addressing and reducing mental health stigma is an essential aspect of providing quality mental health care.

D. Bias is often isolated to inpatient hospitalization: This statement is not accurate. Bias can manifest in various healthcare settings, not just inpatient hospitalization. It is important to address bias across all levels of care to ensure equitable and unbiased treatment for individuals with mental health concerns.

A. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss B. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights C. Knowledge deficit R/T bipolar disorder AEB concern about symptoms D. Risk for suicide R/T powerlessness AEB insomnia and anorexia

Correct Answer is A

Explanation

A. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss: This is the correct priority nursing diagnosis. The client's significant weight loss is indicative of altered nutrition and poses a more immediate threat to their well-being. Addressing the nutritional deficit takes precedence to ensure the client's physical health and stability.

B. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights: While altered sleep patterns are a concern, the priority in this scenario is the significant weight loss, which is indicative of altered nutrition. Nutritional deficits can have more immediate health consequences.

C. Knowledge deficit R/T bipolar disorder AEB concern about symptoms: While addressing knowledge deficits is important for the client's understanding of their condition, the immediate concern is the client's significant weight loss. Nutritional deficits can lead to serious health issues and should be addressed as a priority.

D. Risk for suicide R/T powerlessness AEB insomnia and anorexia: While the client's symptoms may contribute to a risk for suicide, the immediate focus should be on addressing the altered nutrition, which is a more direct threat to the client's physical health.

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Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?

Correct Answer is A

Explanation

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A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

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