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 D
Explanation
Choice A reason: Grandeur involves exaggerated beliefs about one’s importance or power, not misinterpretation of others’ behavior.
Choice B reason: Erotomania is a delusion in which someone falsely believes another person, often famous, is in love with them.
Choice C reason: Flight of ideas is characterized by rapid shifts from one thought to another, common in mania, not misinterpretation of laughter.
Choice D reason: Ideas of reference involve the belief that unrelated events or actions are directed toward oneself, such as assuming group laughter is ridicule.
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.
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