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

Correct Answer: D

Rationale: The correct answer is D because providing personal space respects the client's boundaries and helps prevent escalation of agitation. Maintaining boundaries can reduce feelings of threat and promote a sense of safety for the client. Neon lights and soft music (A) may exacerbate agitation. Maintaining continual eye contact (B) can be perceived as confrontational. While therapeutic touch (C) can be beneficial in some cases, in paranoid schizophrenia it may increase agitation due to mistrust.

Correct Answer: D

Rationale: The correct answer is D: The individual's appraisal of the stressor. This is because how an individual perceives and evaluates a stressor determines their emotional and physiological response. Appraisal involves assessing the significance of the stressor in relation to one's goals, resources, and beliefs. Different individuals may appraise the same stressor differently, leading to varied stress responses. A: The type of stressor is not the most influential factor in determining individual responses to stress, as people can have different reactions to the same stressor based on their appraisal of it. B: The amount of stress does not solely determine the response, as two individuals may experience the same level of stress but react differently based on their appraisal. C: The context of the stressful event is important, but again, it is the individual's interpretation and appraisal of the context that primarily influences their response to stress.

Correct Answer: A

Rationale: The correct answer is A because a patient with cancer experiencing uncontrolled persistent pain meets the eligibility requirement for hospice care. Hospice care focuses on providing comfort and quality of life for patients with terminal illnesses, such as cancer. Persistent pain is a common symptom in cancer patients, and hospice care can help manage it effectively. Choice B is incorrect because having a prognosis of 3 months to live does not automatically qualify a patient for hospice care. Choice C is incorrect because financial constraints are not a determining factor for hospice eligibility, and immobility alone is not sufficient for hospice care. Choice D is incorrect because lacking family support does not determine eligibility for hospice care, and AIDS alone without terminal prognosis may not meet the criteria.

Correct Answer: D

Rationale: The correct answer is D because before offering spiritual support, it is essential for the nurse to understand the client's perceptions and belief system. This step helps tailor the support to the client's individual needs, ensuring it is culturally sensitive and respectful. Option A is incorrect as it jumps to a specific intervention without understanding the client's needs. Option B assumes faith alone can lead to wellness, which may not align with the client's beliefs. Option C focuses on providing religious literature without assessing the client's preferences, potentially missing the mark on effective support.

Correct Answer: B

Rationale: The correct action is to stop and obtain appropriate PPE (Choice B). This ensures the nurse's safety and prevents potential exposure to harmful substances. Leaving PPE in the room (Choice A) is unsafe and violates infection control protocols. Asking a colleague to perform the task (Choice C) may delay care and compromise patient safety. Completing the task (Choice D) without PPE puts the nurse at risk of contamination. Therefore, stopping to obtain PPE is the most appropriate and responsible action in this scenario.