Difficulty: Medium
Average Score: 70%
Simulated
A client with a history of schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. Which intervention should the nurse implement?
Correct answer
C
Rationale
The client is experiencing a paranoid delusion. Providing food in sealed, unopened containers (e.g., individual milk cartons, packaged crackers, canned drinks) is a non-confrontational, practical intervention that addresses the delusion directly by offering tangible proof of safety, thereby increasing the likelihood the client will eat. Telling the client their thinking is irrational (A) directly challenges the delusion and can increase paranoia and aggression. Simply assuring safety (B) relies on logic, which is ineffective against a fixed false belief. Tube feeding (D) is an invasive last resort that should only be considered after all other less restrictive measures, like this one, have failed.