Which nursing intervention would be most appropriate when caring for an acutely agitated

client diagnosed with paranoid schizophrenia?A. Provide neon lights and soft music.B.
Maintain continual eye contact throughout the interview.C. Use therapeutic touch to
increase trust and rapport.D. Provide personal space to respect the client's boundaries.
ANS: DThe most appropriate nursing intervention is to provide personal space to respect the
client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the
client's risk for violence.
15)ThespouseofaclientadmittedtothementalhealthunitforalcoholwithdrawalsaystothenurseI
shouldgetoutofthisbadsituation.Themosthelpfulresponsebythenursewouldbe:
1.
2.
3.

Iagreewithyou.Youshouldgetoutofthissituation.
Whatdoyoufinddifficultaboutthissituation?
Whydontyoutellyourhusbandaboutthis?
Thisisnotthebesttimetomakethatdecision.
15.B.Themosthelpfulresponseisonethatencouragestheclienttoproblemsolve.Givingadviceimplies
thatthenurseknowswhatisbestandcanfosterdependency.Thenurseshouldnotagreewiththeclient,
norshouldthenurserequestthattheclientprovideexplanations.
18.
Thefollowingclientsarewaitingtobeseenintheemergencydepartment.Which
clientshouldthenurseassessfirst?
1.Acocaineabuserwithchestpain.
2.Anintoxicatedclientwithalonghistoryofalcoholism.
3.AclientwhorecentlyexperiencedabadtripfromLSD.
4.Awomanwhothinksshehasbeengivenflunitrazepam(Rohypnol)