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) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.
B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.
C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.
D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.
Correct Answer is D
Explanation
A) Regression involves reverting to earlier developmental behaviors in response to stress. While the client’s current behaviors may reflect regression, her inability to remember specific events points more directly to another mechanism.
B) Denial is the refusal to accept reality or facts. The client acknowledges that her mother ran her father off, so she is not completely denying her past; instead, she seems to lack memory about certain aspects, which suggests a different mechanism.
C) Projection involves attributing one’s own unacceptable feelings or thoughts to someone else. The client is not projecting her feelings onto others; she is reflecting on her own experiences, so this is not the most accurate descriptor.
D) Repression is the unconscious blocking of unacceptable thoughts or memories. The client’s statement about not remembering possible abuse suggests that she may have repressed those memories as a way to cope with the emotional pain associated with her past. This aligns well with the client’s history of chronic depression and suicidal behavior.
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