The nurse is caring for a client with schizophrenia. Which of the following would be a priority nursing goal for this client’s care?

Choice A Reason:

Ask open-ended questions.

While asking open-ended questions can be useful in many therapeutic settings, it may not be the best approach when dealing with delusional clients. Open-ended questions can sometimes lead to more elaborate delusional thinking and may not help in grounding the client in reality. Instead, focusing on the present moment and concrete reality can be more effective in managing delusions.

Choice B Reason:

Focus on what is happening in the here and now.

This is the correct response. Focusing on the present moment helps to ground the client in reality and can reduce the intensity of delusional thoughts. By directing the client’s attention to their immediate environment and current activities, the nurse can help the client stay connected to reality and reduce the impact of their delusions.

Choice C Reason:

Assume knowledge of what is meant when the client talks about “they.”

Assuming knowledge of what the client means when they refer to “they” can reinforce delusional thinking. It is important for the nurse to clarify and understand the client’s perspective without validating the delusion. This approach helps maintain a therapeutic relationship while not reinforcing false beliefs.

Choice D Reason:

Limit contact to one or two short interactions daily.

Limiting contact to one or two short interactions daily is not an effective strategy for managing delusions. Clients with delusions often need consistent and supportive interactions to help them stay grounded in reality. Frequent, brief interactions can provide the necessary support and reassurance without overwhelming the client.

Choice A Reason:

“There is no such thing as the devil. It’s all in your mind.”

This response dismisses the client’s experience and can make them feel invalidated. Telling the client that their experience is “all in your mind” does not acknowledge their distress and can increase their feelings of isolation and mistrust. It is important to validate the client’s feelings while gently orienting them to reality.

Choice B Reason:

“You are not going to hell. You are a good person.”

While this response is supportive, it does not address the client’s immediate distress about hearing voices. It is important to acknowledge the client’s experience of hearing voices and provide reassurance in a way that helps them feel understood and supported. Simply telling them they are a good person may not alleviate their anxiety about the voices.

Choice C Reason:

“Did you take your medicine this morning?”

Asking about medication adherence is important, but it is not the most appropriate immediate response to the client’s distress. This question can come across as dismissive and may not provide the immediate comfort and validation the client needs. It is better to first acknowledge the client’s experience and then address medication adherence later.

Choice D Reason:

“The voices sound distressing, but I don’t hear them.”

This is the correct response. It acknowledges the client’s distress and validates their experience without reinforcing the delusion. By stating that the nurse does not hear the voices, it gently orients the client to reality while showing empathy and understanding. This approach helps build trust and provides comfort to the client.