A nurse is caring for a client on the adult psychiatric unit who is complaining that small children are playing on the floor his room. The care aide informs the nurse that the room is empty. How should the nurse therapeutically respond to the client?

A) I have kids at home, sometimes think I hear them too: This response, though seemingly empathetic, minimizes the client's experience and might make them feel misunderstood. It also brings the nurse's personal experiences into the conversation, which can detract from focusing on the client's current reality and distress.
B) The children may be gone when you're done with therapy, would you like to join the others in the day room?: While this response attempts to redirect the client, it doesn't directly address the client's perception of the children in the room. It can come off as dismissive, as it doesn’t validate the client’s experience or engage with the underlying issue of their perception.
C) Do you know the names of the children?: This response is therapeutic because it gently engages the client in exploring their perception and reality. Asking the client about the children allows them to feel heard and gives the nurse insight into the client’s mental state, possibly indicating a symptom such as hallucinations or delusions, which the nurse can address appropriately.
D) That'd be quite odd; this nursing unit's just for adults: While the nurse is stating a fact, this response can sound dismissive or dismissive of the client’s experience. Instead of validating the client’s perception or gently exploring it, it focuses on the oddity of the situation, potentially making the client feel alienated or disregarded.

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.