A nurse is contributing to the plan of care for a client who is pregnant and reports having trouble sleeping.

Which of the following instructions should the nurse include in the plan of care?

The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.

"The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.

"What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.

"Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.

Applying pressure with gauze helps to control bleeding and promote clotting. The other statements are not accurate or appropriate for circumcision care: "I will apply antibiotic ointment to my baby's penis" is not recommended for Plastibell circumcision. The use of antibiotic ointment is not typically necessary or recommended unless specifically advised by the healthcare provider.

"I will wipe away yellow crusts that form around the incision" should not be done as it may disrupt the healing process. Yellow crusts are a normal part of the healing process and should be left undisturbed.

"I will make sure that my baby's diaper is applied snugly" is unrelated to circumcision care. While proper diapering is important for maintaining hygiene, it does not specifically address the care of the circumcision site.