A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.

Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.

Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.

Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.

Choice A reason: An illusion is a misinterpretation of a real external stimulus, which is not the case here as there is no snake.

Choice B reason: Attention-getting behavior is a possibility, but given that Mr. G is specifically referencing a snake that isn't there, it suggests a hallucination.

Choice C reason: A hallucination is a sensory perception in the absence of external stimuli, which fits Mr. G's description of seeing a snake that isn't there.

Choice D reason: A delusion is a firmly held false belief; while Mr. G may have this, the immediate experience he's describing is a hallucination, not a delusion.