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. "Why do you think you are being lied about and poisoned?": This question may come across as confrontational or challenging, potentially increasing the client's anxiety or defensiveness. It's important to acknowledge the client's feelings rather than questioning their beliefs directly.

B. "You are mistaken. Nobody is lying about you or trying to poison you.": This statement is dismissive and may cause the client to feel invalidated. It is crucial to acknowledge the client's feelings and experiences, even if they are not based on reality.

C. "Who is lying about you and trying to poison you?": This question may unintentionally reinforce the delusional thinking by suggesting that someone is indeed lying or trying to poison the client. It's essential to avoid validating or encouraging the delusional content.

D. "You seem to be having very frightening thoughts.": This statement acknowledges the client's emotions without directly challenging the delusional content. It shows empathy and creates an open and non-confrontational environment, allowing the client to express their feelings and experiences.

A. Case Manager B. Educator C. Counselor D. Milieu Manager

Correct Answer is D

Explanation

A. Case Manager:

A case manager is typically responsible for coordinating and managing the overall care and services for a client. This role involves collaboration with various healthcare professionals and services outside the immediate treatment setting.

B. Educator:

An educator is involved in providing information, teaching, and promoting the understanding of health-related topics. While education is an essential component of nursing care, the described actions are more indicative of another role.

C. Counselor:

A counselor focuses on providing emotional support, guidance, and therapeutic communication to help clients explore and address personal issues. While nurses do engage in counseling, the described actions emphasize a broader role.

D. Milieu Manager:

The role of a milieu manager involves organizing and maintaining the therapeutic environment, including scheduling activities, managing interactions, and ensuring safety on a psychiatric unit. This role is crucial for creating a supportive and therapeutic atmosphere for clients.

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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

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