The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

Explain that these beliefs are related to her illness.

Explain that distrust is related to feeling anxious.

Initiate short, frequent contacts with the client.

Offer to keep the belongings at the nurse's desk.

Answer and Explanation

The Correct Answer is C

(A) Explain that these beliefs are related to her illness: While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.

(B) Explain that distrust is related to feeling anxious: This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.

(C) Initiate short, frequent contacts with the client: This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.

(D) Offer to keep the belongings at the nurse’s desk: This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

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Correct Answer is C

Explanation

A) Returning at a later time to talk might seem considerate, but it may miss the opportunity to engage with the client in the moment. The client may benefit from having the nurse's presence and support, even if they are slow to respond.

B) Asking a different question could disrupt the process and prevent the client from expressing their feelings. It’s important to allow the client the space to answer the original question rather than shifting topics prematurely.

C) Waiting for the client to respond is the best action. This approach demonstrates patience and respect for the client's current state. By allowing time for a response, the nurse can create a supportive environment, which may help the client feel more comfortable opening up when they are ready.

D) Asking if the client heard the question might feel like an interruption or could add pressure, making the client more anxious. It’s better to give the client space to process and respond without feeling judged or rushed.

A. Praise her for the new behavior. B. Offer her a choice of activities. C. Involve her in group therapy. D. Observe her actions continuously.

Correct Answer is D

Explanation

A) Praising the client for her new behavior can be encouraging and may boost her self-esteem. However, it’s essential to approach this cautiously, as excessive praise might overwhelm her or be perceived as insincere. While positive reinforcement is valuable, it should not be the sole focus of the intervention.

B) Offering her a choice of activities can promote autonomy and encourage engagement, but given her recent shift from despondency to exhibiting energy, it’s crucial to assess her mood and mental state carefully first. Providing choices may be helpful, but it should be accompanied by vigilant monitoring to ensure her safety.

C) Involving her in group therapy could facilitate social interaction and support, but it may not be appropriate immediately. After several days of nonverbal behavior, she may still be vulnerable. Group settings could be overwhelming, and her readiness to participate should be carefully evaluated.

D) Observing her actions continuously is the most critical action at this stage. The change in her behavior—from being despondent and nonverbal to talking and exhibiting energy—can indicate a potential shift toward increased risk for impulsivity or self-harm. Continuous observation allows the nurse to assess her safety and intervene if her behavior escalates, ensuring she is supported during this transitional phase.

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The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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