Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?
Provide personal space to respect the clients boundaries
Maintain continual eye contact throughout the interview
Provide neon lights and soft music
use therapeutic touch to increase trust and rapport
The Correct Answer is A
A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.
B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.
C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.
D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications: The symptoms described (uncontrollable tongue movements, stiff neck, difficulty swallowing) are more indicative of tardive dyskinesia than neuroleptic malignant syndrome. Neuroleptic malignant syndrome is characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity. Treatment involves discontinuing antipsychotic medications and supportive care.
B. Agranulocytosis treated by administration of clozapine (Clozaril): Agranulocytosis is a rare but serious side effect of clozapine, not a treatment for the symptoms described. The symptoms presented are more consistent with tardive dyskinesia.
C. Tardive dyskinesia treated by discontinuing antipsychotic medication: This is the correct answer. Tardive dyskinesia is a movement disorder characterized by involuntary and abnormal movements, including tongue protrusion and facial grimacing. It can result from long-term use of antipsychotic medications, and discontinuing or reducing the dose of the antipsychotic is a primary intervention.
D. Headache treated by administration of Hydrochlorothiazide: Hydrochlorothiazide is a diuretic used to treat conditions like high blood pressure and edema, not headache or the symptoms described, which are more indicative of tardive dyskinesia.
Correct Answer is A
Explanation
A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.
B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.
C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.
D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.
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