The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
Explain that these beliefs are related to her illness.
Explain that distrust is related to feeling anxious.
Initiate short, frequent contacts with the client.
Offer to keep the belongings at the nurse's desk.
The Correct Answer is C
(A) Explain that these beliefs are related to her illness: While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.
(B) Explain that distrust is related to feeling anxious: This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.
(C) Initiate short, frequent contacts with the client: This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.
(D) Offer to keep the belongings at the nurse’s desk: This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.
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Related Questions
Correct Answer is C
Explanation
(A) Explain that these beliefs are related to her illness:While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.
(B) Explain that distrust is related to feeling anxious:This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.
(C) Initiate short, frequent contacts with the client:This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.
(D) Offer to keep the belongings at the nurse’s desk:This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.
Correct Answer is D
Explanation
A) Request backup from the staff:Requesting backup may be necessary if the situation escalates and the client poses a threat to themselves or others. However, it should not be the first action. The nurse should initially attempt to de-escalate the situation by addressing the client’s immediate needs and providing personal space.
B) Encourage the client to sit down:Encouraging the client to sit down might help reduce their agitation, but it could also be perceived as controlling or dismissive. The nurse should first focus on creating a safe environment by providing personal space and then assess the client’s willingness to sit down.
C) Stand in the doorway:Standing in the doorway can provide the nurse with a quick exit if needed, but it may also make the client feel trapped or cornered. It is important to maintain a non-threatening posture and ensure the client has enough space to feel comfortable.
D) Provide for personal space:Providing personal space is crucial in managing aggressive behaviors. It helps to reduce the client’s sense of threat and allows them to feel more in control. This approach can help de-escalate the situation and create a safer environment for both the client and the nurse.
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