A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?
Use clear, calm statements and a confident physical stance
Provide objective evidence that violence is unwarranted.
Empathize with the clients paranoid perceptions.
initially restrain the client to maintain safety
The Correct Answer is A
A. Use clear, calm statements and a confident physical stance:
This is the most appropriate choice. Clear and calm communication, along with a confident physical stance, can help to de-escalate the situation. It demonstrates assertiveness and can potentially prevent further escalation of violence.
B. Provide objective evidence that violence is unwarranted:
While providing objective evidence may be helpful in some situations, individuals with paranoid personality disorder may not respond well to attempts to prove that their perceptions are unwarranted. It could potentially escalate the situation.
C. Empathize with the client's paranoid perceptions:
While empathy is important in communication, empathizing with paranoid perceptions in a way that validates or reinforces them may not be the best approach. It could inadvertently validate the client's distorted thoughts and potentially escalate the situation.
D. Initially restrain the client to maintain safety:
Physical restraint should be a last resort and used only when the safety of the client or others is at immediate risk. Initial restraint can escalate aggression and may not be the most appropriate intervention in the early stages of a violent episode.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Generalized anxiety disorder and a nursing diagnosis of fear: Generalized anxiety disorder typically involves chronic, excessive worrying and anxiety that is not limited to specific situations or triggers. The sudden and intense symptoms described in the scenario, such as lightheadedness, tremulousness, diaphoresis, tachycardia, and dyspnea, are more indicative of a panic attack rather than generalized anxiety. The nursing diagnosis of fear may not fully capture the acute and intense nature of panic symptoms.
B. Panic disorder and a nursing diagnosis of panic anxiety: This is the correct answer. Panic disorder is characterized by recurrent, unexpected panic attacks, which align with the sudden onset of symptoms described in the scenario. The nursing diagnosis of panic anxiety is appropriate as it addresses the acute distress associated with panic attacks.
C. Pain disorder and a nursing diagnosis of altered role performance: There is no indication of pain being the primary issue in this scenario. The symptoms are more indicative of a panic attack rather than a pain disorder. Additionally, altered role performance is not a priority nursing diagnosis when addressing the acute symptoms of a panic attack.
D. Altered sensory perception and a nursing diagnosis of panic disorder: Altered sensory perception is not the primary issue in this scenario, and it does not specifically address the sudden and intense symptoms described. The focus should be on the panic symptoms and the associated distress, leading to the nursing diagnosis of panic anxiety.
Correct Answer is A
No explanation
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.