A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take?

Explain to the client that the delusional material is not possible.

Explore the meaning of the delusion with the client.

Acknowledge the feelings the client is experiencing regarding the delusion.

Interact with the client as if the content of the delusion were true.

Answer and Explanation

The Correct Answer is C

Choice A reason: Telling the client the delusion is not possible is confrontational and ineffective. Clients may not accept reality testing during active delusions.

Choice B reason: Exploring the meaning of the delusion focuses attention on false beliefs, reinforcing them rather than redirecting.

Choice C reason: Acknowledging feelings validates the client’s emotional experience without reinforcing the delusion. This maintains therapeutic communication and supports reality orientation.

Choice D reason: Interacting as if the delusion were true reinforces psychosis and is inappropriate.

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Correct Answer is B

Explanation

Choice A reason: An overly friendly attitude may increase suspicion in a client with paranoia. A calm, neutral approach is more therapeutic.

Choice B reason: Allowing the client to unwrap food items helps reduce paranoia about tampering or poisoning. This intervention promotes trust and reduces anxiety.

Choice C reason: Using touch can be misinterpreted and increase paranoia or agitation. Physical contact should be avoided unless necessary for safety.

Choice D reason: Rotating staff frequently can increase mistrust. Consistency in caregivers helps build rapport and reduce paranoia.

A. Protecting the client from self-harm behavior B. Providing strategies for redirecting violent behavior C. Encouraging the client to talk about her feelings D. Exploring reasons for her behavior

Correct Answer is A

Explanation

Choice A reason: Clients with borderline personality disorder are at high risk for self-harm and suicidal behavior. Protecting the client from self-injury is the priority intervention to ensure safety.

Choice B reason: Redirecting violent behavior is important but secondary to preventing self-harm. Violence may occur, but self-injury is more immediate and life-threatening.

Choice C reason: Encouraging expression of feelings is therapeutic but not the priority when safety is at risk. Emotional exploration can occur after stabilization.

Choice D reason: Exploring reasons for behavior is useful for long-term therapy but is not the immediate priority in acute care.

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A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take?

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