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 B
Explanation
Choice A reason: While mood stabilizers are essential in treatment, medication cannot be safely administered before completing an assessment of risk and safety.
Choice B reason: The priority in this scenario is to assess safety, as John is at risk of harming himself or others due to reckless behavior during mania and suicidal ideation during depression. Safety always precedes treatment or education.
Choice C reason: Therapy is a valuable part of long-term management, but it is not the immediate priority when safety concerns exist.
Choice D reason: Education is important but cannot come before determining immediate risk and ensuring safety.
Correct Answer is B
Explanation
Choice A reason:Collecting a blood specimen can help evaluate electrolyte levels, liver function, or alcohol levels, which is important in managing alcohol withdrawal. However, it is not the immediate priority, as addressing life-threatening risks like seizures takes precedence in the acute phase.
Choice B reason:Acute alcohol withdrawal carries a high risk of seizures, which can be life-threatening. Implementing seizure precautions, such as padding the environment and ensuring access to emergency medications, is the first priority to ensure the client’s safety.
Choice C reason:A neurological exam is useful to assess the client’s mental status and neurological function during withdrawal. However, it is not the first action, as preventing seizures, which pose an immediate danger, is more urgent.
Choice D reason:Inserting an IV access site is necessary for administering fluids or medications like benzodiazepines to manage withdrawal symptoms. However, ensuring seizure precautions are in place is the first step to address immediate safety risks.
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