A nurse is caring for a client at the clinic.

Exhibits

Complete the following sentence by

The client is at risk for

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due to

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A. Rotate staff members caring for the client. Clients with paranoid personality disorder often struggle with mistrust and feel suspicious of others. Consistency in staffing is important to build rapport and reduce anxiety, so rotating staff can worsen paranoia.
B. Speak in a neutral tone when addressing the client. This is appropriate because a calm, neutral, and non-threatening tone helps reduce perceived threats or suspicion. It promotes a sense of safety and control, which is important for therapeutic communication with paranoid individuals.
C. Limit the client's opportunities to socialize with others. While clients with paranoid personality disorder may prefer limited interaction, completely restricting socialization can increase isolation and reinforce delusional thinking. Structured, safe interactions are often encouraged.
D. Mix the medication with the client's food items. Administering medication without the client’s knowledge is deceptive and unethical, especially in someone already prone to distrust. Open and honest communication about treatment is crucial for promoting cooperation and trust.

A. Ensure the formula is cold before administration. Enteral formula should be given at room temperature to avoid causing gastrointestinal cramping or discomfort. Cold formula can irritate the GI tract and lead to intolerance.
B. Check placement of the feeding tube by x-ray once daily. An x-ray is used initially to confirm tube placement after insertion, but daily x-rays are not required. Ongoing checks are done through aspirate checks and measuring external tube length.
C. Maintain the head of the client's bed at a 20° angle or higher. The head of the bed should be elevated to at least 30 to 45 degrees to prevent aspiration. A 20° angle is insufficient and increases the risk of aspiration pneumonia.
D. Check gastric residuals every 4 hr. This is appropriate for clients receiving continuous feedings. Monitoring gastric residual volume (GRV) every 4 hours helps assess tolerance to the feeding and reduces the risk of aspiration.
E. Change the feeding container and tubing every 24 hr. To prevent bacterial contamination, the feeding bag and tubing should be changed every 24 hours when using an open system. This is a standard infection control practice.