A client states to the nurse, "I'm using my telepathic brain power to force the doctor to discharge me." This is likely an example of which delusion?

C) Offer the client a physical outlet

Encouraging the client to engage in a physical activity, such as walking or using a stress ball, helps release pent-up energy in a non-threatening way. This approach aligns with de-escalation techniques, which should be attempted before pharmacologic or restrictive interventions.

D) Offer the client medication

If the client's agitation continues despite non-pharmacologic interventions, offering as-needed medication (such as an anxiolytic or antipsychotic) may help manage escalating aggression. Medication should be a secondary measure after attempting verbal de-escalation and physical outlets.

A) Place the client in restraints

Restraints are a last resort and should only be used if the client poses an immediate danger to themselves or others after all other de-escalation strategies have failed.

B) Grab the client’s hand

Physically intervening without the client’s consent can increase aggression and pose a safety risk for both the client and the nurse. Maintaining a safe distance is a better approach.

A) I will sit here with you for 10 minutes: This response is the most therapeutic because it shows the nurse’s willingness to be present with the client without pressuring them for interaction. Sitting quietly with the client provides comfort and reassurance, acknowledging their feelings while respecting their need for space. It is important for clients with depression to feel supported, even if they cannot engage in conversation at the moment.

B) I will find someone else for you to talk with: While this response may seem considerate, it could be interpreted as abandoning the client or suggesting they are not worthy of the nurse's attention. The client might feel more isolated or rejected. The priority is to offer comfort and consistency, not to remove oneself from the situation immediately.

C) I will come back a little bit later: While giving the client some time and space is important, this response may not be as therapeutic as simply remaining with the client. It suggests the nurse is unwilling to be present now, which could make the client feel neglected. It’s better to offer calm and supportive presence at the moment, rather than withdrawing.

D) I will get you something to read: Offering something to read can be helpful for some clients, but in this situation, where the client is displaying a flat affect and psychomotor retardation, this response may be too focused on distracting or diverting the client from their emotional state. The priority is to stay with the client and offer a calm, supportive presence rather than immediately introducing distractions.