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:A neologism is a made-up word or phrase that has meaning only to the person using it, often seen in schizophrenia. The client’s repeated use of "flakala," a non-existent word, indicates the creation of a term unique to their thought process, fitting the definition of a neologism.
Choice B reason:Word salad refers to a jumbled, incoherent string of words or phrases that lack meaningful connection, making communication difficult to understand. The client’s statement is repetitive and focused on a single invented word, not a disorganized mix of unrelated words, so this does not apply.
Choice C reason:Echolalia involves repeating words or phrases spoken by others, often seen in conditions like autism or schizophrenia. The client is not mimicking someone else’s speech but is using a self-created word, so echolalia is not the correct description.
Choice D reason:Clang association is when words are chosen based on their sound, such as rhyming or alliteration, rather than meaning. The client’s use of "flakala" does not involve sound-based word choices but rather the invention of a new word, making this choice incorrect.
Correct Answer is C
Explanation
Choice A reason:Clozapine is an antipsychotic used primarily for schizophrenia, not for preventing seizures. While it may lower the seizure threshold as a side effect, it is not prescribed for seizure control, making this statement incorrect.
Choice B reason:Clozapine is typically administered orally, not by intramuscular injection every 2 weeks. Long-acting injectable antipsychotics exist, but clozapine is not one of them, so this statement does not reflect correct understanding.
Choice C reason:Clozapine can cause orthostatic hypotension, leading to dizziness or fainting upon standing. Rising slowly from a lying position helps prevent this, indicating the client understands an important precaution for safe use of the medication.
Choice D reason:Ringing in the ears (tinnitus) is not a common side effect of clozapine. More common side effects include sedation, weight gain, and agranulocytosis, so this statement does not show correct understanding.
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