A 45-year-old client with a delusional disorder believes that their neighbor is spying on them through hidden cameras in their home. The client is anxious but willing to discuss their belief. What is the most appropriate nursing response to support reality testing?
"That’s impossible. Your neighbor wouldn’t do that."
"You should stop worrying about this; it’s not real."
"If you think there are cameras, we should find them together."
"I understand this is frightening for you. I haven’t seen any cameras, and the police haven’t found anything. Let’s talk about what might help you feel more secure."
The Correct Answer is D
Choice A reason: Directly rejecting the belief is non-therapeutic and may increase defensiveness, damaging trust.
Choice B reason: Telling the client to stop worrying invalidates their feelings and dismisses the emotional impact of the delusion.
Choice C reason: Participating in the delusion by “looking for cameras” reinforces the false belief, which is not supportive of reality testing.
Choice D reason: Acknowledging the client’s fear while gently presenting reality and shifting toward problem-solving helps maintain trust and supports reality testing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Secondary interventions focus on early detection and intervention for individuals at risk to prevent progression of a problem. Identifying those at higher risk for suicide allows for targeted interventions, such as counseling or monitoring, to prevent attempts, making this a secondary intervention.
Choice B reason:Performing life-saving measures is a tertiary intervention, aimed at reducing harm after a suicide attempt has occurred. It focuses on recovery rather than prevention, so it is not a secondary intervention.
Choice C reason:Supporting family and friends after a suicide is a tertiary intervention, addressing the aftermath of the event to aid recovery and coping. It does not prevent the initial act, so it is not a secondary intervention.
Choice D reason:Recognizing warning signs is a primary intervention, aimed at prevention through awareness and education before risk escalates. It precedes identifying specific at-risk individuals, so it is not a secondary intervention.
Correct Answer is A
Explanation
Choice A reason: Allowing the client to describe the event in their own words is essential for initial assessment, evidence collection, and emotional support.
Choice B reason: A bed bath would destroy physical evidence needed for forensic examination.
Choice C reason: Discussing self-defense techniques at this time is inappropriate, as the focus should be on immediate safety, support, and care.
Choice D reason: Photographs may be taken, but the nurse should not present them as required for police reporting, as this can increase trauma and coercion.
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