A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?

Choice A Reason: While this response may seem compassionate, it does not encourage the client to engage in activities that could benefit their mental health. Allowing the client to remain isolated may reinforce feelings of helplessness or depression. It is important to motivate clients to participate in therapeutic activities to promote their recovery.

Choice B Reason: This response is supportive and offers a compromise. It acknowledges the client’s current state and provides assistance, while also gently encouraging participation in activities. By offering help and allowing for rest afterward, the nurse is using an empathetic approach to facilitate the client’s involvement in the unit’s programs.

Choice C Reason: This response is coercive and could be considered a threat. It is not therapeutic to withhold basic needs such as meals as a form of punishment or to force compliance. Such an approach can damage the nurse-client relationship and is not conducive to the client’s recovery.

Choice D Reason: This response may come across as dismissive and demanding. It does not offer support or acknowledge the client’s feelings. Telling the client what they “need” to do without offering help or understanding can lead to resistance and a lack of trust in the nurse-client relationship.

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.