A 70-year-old client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out?" Which of the following would be the most therapeutic response by the nurse?

A. Delusions of reference - Delusions of reference involve a false belief that unrelated events or objects in the environment have a special and personal meaning for the individual. This is not related to the client's difficulty in staying focused on a topic.
B. Tangentiality - Tangentiality involves going off on tangents when speaking but usually returning to the main topic eventually. It is different from loose associations, as the thoughts do not derail as severely.
C. Neologism - Neologism refers to the creation of new words or expressions that have no known meaning, often seen in severe thought disorder, but it is not directly related to the client's difficulty in staying focused or hearing voices.
D. Loose associations.
Loose associations, also known as "loosening of associations" or "derailment," is a thought disturbance commonly seen in schizophrenia. It involves a disorganized pattern of thinking in which the person's thoughts become disconnected or derail from the main topic of conversation. The individual may jump from one idea to another without a clear and logical link between them. This is often accompanied by impaired concentration and the inability to stay focused on a particular topic.

A.This response is not appropriate because it does not address the client’s confusion or provide orientation. It may also increase the client’s agitation by suggesting an activity that is not relevant to their immediate concern.

B.This response is dismissive and does not acknowledge the client’s distress or confusion. It fails to provide orientation or reassurance, which are crucial in managing delirium.

C.While this response provides some information about safety, it does not orient the client to their current situation or address their immediate concern. It may also increase the client’s anxiety by focusing on the restriction rather than offering reassurance.

D.This is the most therapeutic response as it provides clear, factual information that helps orient the client to their current situation. It reassures the client by reminding them that they are in a safe place and under the care of a nurse, which can help reduce confusion and anxiety.