A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate?
A. Provide objective evidence that violence is unwarranted.
B. Initially restrain the client to maintain safety.
C. Use clear, calm statements and a confident physical stance.
D. Empathize with the client's paranoid perceptions.
C
The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.
You might also like to view...
The nurse is evaluating the risk for metastasis after a client is diagnosed with breast cancer. Which lymph node involvement would indicate the greatest likelihood of metastasis for this client?
1. A. 2. B. 3. C. 4. D.
The homecare nurse is examining a newborn who is sleeping in a basket on a pillow, covered with a fluffy blanket. There is also a stuffed animal in the basket. The most important nursing action is to:
1. Remove the stuffed animal from the basket and place it on the floor. 2. Teach the parents the risk of SIDS from soft items in the infant's bed. 3. Make certain that the blanket is firmly tucked under the baby. 4. Ask whether the color of the blanket has cultural significance.
The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client?
1. Help the client look for available community resources that may be of assistance. 2. Tell the client that she needs to take the prescribed amount. 3. Report the situation to the physician. 4. Weigh the client on a weekly basis to monitor weight gain or loss.
The nurse completes postoperative discharge teaching to the parents of a child who had a tonsillectomy. Which statement by the parents indicates correct understanding of the teaching session?
1. "We will call the physician for any indication of ear pain." 2. "We will plan on administering acetaminophen (Tylenol) for pain." 3. "We will be sure to give our child adequate amounts of citrus juices." 4. "We will keep our child on bed rest for 10 days after the surgery."