A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Use touch to calm the client during periods of anxiety

Check the clients mouth after the client takes medication

Rotate the staff assignments for this client

Assign an assistive personnel to feed the client at meat times

Answer and Explanation

The Correct Answer is B

A. Use touch to calm the client during periods of anxiety:

Individuals with paranoid schizophrenia may have heightened sensitivity to touch, and it can potentially exacerbate their anxiety or paranoia. This intervention may not be appropriate as it could escalate the client's distress.

B. Check the client's mouth after the client takes medication:

This is the best choice. People with paranoid schizophrenia may be prone to hoarding or pocketing medications. Checking the client's mouth ensures that the medication has been swallowed, promoting medication adherence and preventing potential harm.

C. Rotate the staff assignments for this client:

Consistency in caregivers is generally preferred for clients with schizophrenia to build trust and a therapeutic relationship. Constantly changing staff assignments can lead to increased anxiety and mistrust.

D. Assign an assistive personnel to feed the client at meal times:

While assistance with feeding may be needed, assigning an assistive personnel without direct supervision for a client with paranoid schizophrenia may not be the best approach. It's important to ensure the client's safety and monitor their behavior during meals.

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Correct Answer is ["B","C","D"]

Explanation

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself. B. I’m so sorry you cut your arms Let's discuss how you were feeling C. Wow. what happened to you?". D. What did you use to cut yourself! I will need to search your room

Correct Answer is A

Explanation

A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself."

This response is the most therapeutic. It acknowledges the patient's self-harm behavior, addresses the immediate physical needs by offering to clean the wounds, and encourages the patient to reflect on their emotions through journaling. This approach promotes self-awareness and provides a constructive coping strategy.

B. "I’m so sorry you cut your arms. Let's discuss how you were feeling."

This response is empathetic and encourages communication about the patient's emotions. While it acknowledges the self-harm and invites discussion, it does not suggest a specific coping strategy like journaling. It is still a supportive and therapeutic approach.

C. "Wow. What happened to you?"

This response may come off as judgmental or dismissive. It does not acknowledge the patient's emotional state or offer immediate support for the physical wounds. The tone and wording may make the patient feel uncomfortable or judged.

D. "What did you use to cut yourself! I will need to search your room."

This response is not therapeutic and may be perceived as confrontational and invasive. It does not prioritize the patient's emotional well-being and may violate the patient's trust and privacy. Searching the room without consent is not a recommended approach.

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A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

Correct Answer is A

Explanation

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