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NCLEX-RN · Question #167

A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be:

The correct answer is D. "I know that must be frightening for you; let the staff know when you are having thoughts that. (A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client's delusional system may force the client to defend…

Psychosocial Integrity

Question

A client experiencing delusions states, "I came here because there were people surrounding my house that wanted to take me away and use my body for science." The best response by the nurse would be:

Options

  • A"Describe the people surrounding your house that want to take you away."
  • B"I need more information on why you think others want to use your body for science."
  • C"There were no people surrounding your house, your relatives brought you here, and no one really
  • D"I know that must be frightening for you; let the staff know when you are having thoughts that

How the community answered

(19 responses)
  • A
    5% (1)
  • B
    5% (1)
  • C
    16% (3)
  • D
    74% (14)

Explanation

(A) Focusing on the delusional content does not reinforce reality. (B) Pursuing details or more information on the delusion reinforces the false belief and further distances the client from reality. (C) Challenging the client's delusional system may force the client to defend it, and you cannot change the delusion through logic. (D) Focusing on the feeling can reinforce reality and discourage the false belief. Seeking out staff when thoughts are troublesome can help to decrease anxiety.

Topics

#delusions#therapeutic communication#schizophrenia#reality orientation

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