Question

Question was provided via image upload.

Explanation:

Analyze the client's diagnosis and clinical needs

The client has paranoid schizophrenia. Key nursing considerations for paranoid schizophrenia include managing paranoia, ensuring safety, establishing trust, and ensuring medication adherence. Clients with paranoia often experience delusions of persecution, which can make them suspicious of others, including healthcare staff, and may lead to "cheeking" medications (holding pills in the mouth without swallowing them).

Evaluate the first option

Using the Schizophrenia Management knowledge point

• Touch can be perceived as threatening, invasive, or a physical violation by a client experiencing paranoia or active delusions.
• Physical touch should generally be avoided or used with extreme caution and only with the client's explicit permission.

Evaluate the second option

Using the Schizophrenia Management knowledge point

• Clients with paranoid schizophrenia may attempt to cheek medications due to suspicion or fear of being poisoned.
• Checking the client's mouth after medication administration is a standard, necessary safety intervention to ensure the medication is actually swallowed and to maintain therapeutic adherence.

Evaluate the third option

Using the Schizophrenia Management knowledge point

• Assigning assistive personnel to feed the client is inappropriate because clients with paranoid schizophrenia are typically physically capable of feeding themselves.
• Furthermore, introducing unfamiliar staff to feed them can increase suspicion and paranoia regarding food safety.

Evaluate the fourth option (partially visible)

Using the Schizophrenia Management knowledge point

• The partially cut-off option mentions "assignments for this client" (likely referring to rotating staff assignments).
• For a paranoid client, rotating staff frequently is counterproductive; maintaining consistent staff assignments is crucial to building trust and reducing anxiety.
• Therefore, checking the mouth after medication administration is the most appropriate and standard intervention among the visible choices.

Answer:

• Use touch to calm the client during periods of anxiety.
• Check the client's mouth after the client takes medication. (Correct answer)
• Assign an assistive personnel to feed the client at mealtimes.
• Rotate staff assignments for this client.