A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

Serve individual items that have sealed packaging.

Serve warm foods that arrive from the kitchen with lids in place.

Serve the same food that other clients in the dining room are eating.

Serve the client's favorite foods in an attractive arrangement.

Answer and Explanation

The Correct Answer is A

Choice A reason: Serving food in sealed packaging can help alleviate the client's fears of poisoning, as the intact seals provide visual assurance that the food has not been tampered with.

Choice B reason: While serving warm foods with lids may keep the food warm, it does not necessarily provide the same level of reassurance against the fear of poisoning as sealed packaging does.

Choice C reason: Serving the same food as others may not be effective if the client's delusions include beliefs that they are being specifically targeted.

Choice D reason: Although serving the client's favorite foods in an attractive arrangement may be appealing, it does not address the specific paranoid delusion of food being poisoned.

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Correct Answer is D

Explanation

Choice A reason: Setting consequences just before the behavior occurs does not provide clear expectations and boundaries for the patient.

Choice B reason: Setting consequences after the behavior is done may not effectively prevent the behavior and can lead to inconsistent enforcement.

Choice C reason: Waiting for complaints before setting consequences can lead to a reactive rather than proactive approach to care.

Choice D reason: Consequences should be clearly communicated when the limit is set to establish clear boundaries and expectations, which is essential in managing patients with personality disorders.

A. Vomiting B. Urticaria C. Low back pain D. Pulmonary congestion

Correct Answer is C

Explanation

Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.

Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.

Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.

Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.

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A nurse is caring for a client who has paranoid delusions and believes the hospital food is being poisoned by the staff. Which meal presentation should the nurse consider to be an effective method of encouraging nutritional intake?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When setting limits with patients with personality disorders, the consequences of violating those limits should be set at which time?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Correct Answer is C

Explanation

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