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 C
Explanation
Choice A reason:A 3 mg additional dose would exceed the prescribed limit. The prescription allows for 1 mg every 8 hours as needed, up to a maximum of 3 mg in a 24-hour period (one dose every 8 hours). Since the patient has already received 2 mg (two 1 mg doses), an additional 3 mg would result in a total of 5 mg, which is unsafe and exceeds the prescribed daily limit.
Choice B reason:A 2 mg additional dose would also exceed the prescribed limit. With 2 mg already taken, an additional 2 mg would total 4 mg in a day, surpassing the maximum of 3 mg allowed by the prescription (1 mg every 8 hours, up to three doses).
Choice C reason:The patient has already received 2 mg (two 1 mg doses) today. The prescription allows for 1 mg every 8 hours as needed, which permits a maximum of 3 mg in 24 hours. With two doses already administered, only one additional 1 mg dose is safe, but none of the options list 1 mg. Therefore, 0 mg is the correct answer, as no additional dose beyond the remaining 1 mg is permissible among the given choices.
Correct Answer is D
Explanation
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.
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