NCLEX-RN · Question #640
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks…
The correct answer is A. "I don't see your mother in the room. Let's talk about how you're feeling.". (A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse…
Question
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
Options
- A"I don't see your mother in the room. Let's talk about how you're feeling."
- B"OK, I'll come back later when you're feeling more like taking your medicine."
- C"She may be here, but I can't see her."
- D"Why don't you finish talking to her, and I'll wait."
How the community answered
(35 responses)- A80% (28)
- B11% (4)
- C3% (1)
- D6% (2)
Explanation
(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.
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