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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Provide client with high-calorie finger foods throughout the day:

While providing high-calorie finger foods may increase caloric intake, it may not be the most effective strategy for a specific weight gain goal. It's essential to encourage a balanced and varied diet.

B. Teach the importance of a varied diet to meet nutritional needs:

This is a good general approach to promote overall nutritional health, but it may not be specific enough to address the immediate goal of gaining 2 pounds within a week.

C. Initiate total parenteral nutrition to meet dietary needs:

Total parenteral nutrition is an invasive and aggressive intervention typically reserved for cases where oral or enteral feeding is not possible or insufficient. It is not the first-line approach for someone who can consume food orally.

D. Accompany client to cafeteria to encourage adequate dietary consumption:

This is the most appropriate intervention. Accompanying the client to the cafeteria provides an opportunity for direct encouragement and support during meals. It helps ensure that the client is consuming an adequate amount of food, which is crucial for the goal of gaining 2 pounds within a week.

A. Orientation B. Affect C. Perception D. Mood

Correct Answer is A

Explanation

Orientation: When a nurse asks a client to identify their name, date, residential address, and situation, they are assessing the client's orientation. Orientation refers to an individual's awareness of time, place, person, and situation.

B. Affect: Affect refers to the observable expression of emotions. It involves the client's emotional tone, such as being happy, sad, angry, or flat. It is not directly assessed by asking about personal information.

C. Perception: Perception involves the way individuals interpret and make sense of sensory information. Asking about personal information is more related to orientation than perception.

D. Mood: Mood refers to a more sustained emotional state. It is not directly assessed by asking for specific personal information about the current situation or location.

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Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week?

Correct Answer is D

Explanation

What is being assessed when a nurse asks a client to identify name date, residential address, and situation?

Correct Answer is A

Explanation

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