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 D

Explanation

A. Concern for others: Individuals with antisocial personality disorder typically lack genuine concern for others and may exploit or manipulate them for personal gain.

B. Actively engaged in all unit activities: While engagement in activities can vary, the key feature of antisocial personality disorder is not a high level of engagement but rather a disregard for rules and the rights of others.

C. Mindful of following all of the unit rules: Individuals with antisocial personality disorder often have a history of rule-breaking and may not be consistently mindful of following societal or institutional rules. They may engage in behaviors that violate rules or laws.

D. Manipulative: This is the correct answer. Antisocial personality disorder is characterized by manipulative behaviors, where individuals exploit others for personal gain or pleasure. Manipulation is a key feature of this disorder.

A. Maintain consistency of care by open communication to avoid staff manipulation B. Maintain unit order by the application of autocratic leadership C. Allow the clients to apply the democratic process when developing unit rules D. Allow the client spokesperson to verbalize concerns during a unit staff meeting

Correct Answer is A

Explanation

A. Maintain consistency of care by open communication to avoid staff manipulation: This is the correct answer. Borderline personality disorder (BPD) clients may engage in splitting behaviors, which involve polarized views of staff as either all good or all bad. Maintaining consistency of care and open communication can help prevent manipulation and ensure fair and transparent interactions.

B. Maintain unit order by the application of autocratic leadership: Autocratic leadership, characterized by a top-down approach with limited input from others, may not be the most effective strategy in this situation. It may lead to resistance from clients and potentially escalate the conflict.

C. Allow the clients to apply the democratic process when developing unit rules: While democratic processes are generally beneficial, allowing clients to unreasonably demand modifications of unit rules without considering the overall impact on the therapeutic environment may not be appropriate. It's important to balance client involvement with maintaining a structured and therapeutic milieu.

D. Allow the client spokesperson to verbalize concerns during a unit staff meeting: While it's important to provide a platform for clients to express concerns, allowing a spokesperson to verbalize concerns during a staff meeting should be done in a manner that maintains order and follows the therapeutic goals of the unit. It should not involve unreasonably demanding modifications without a careful consideration of the impact on the overall treatment milieu.

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

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Naxlex Comprehensive Predictor Exams

The patient admitted with antisocial disorder will display which symptom(s)?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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