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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.
Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.
Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.
Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.
Correct Answer is A
Explanation
Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.
Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.
Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.
Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.
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