Which of the following nursing strategies would be most appropriate when caring for an individual who is delusional?

Choice A Reason:

Uses relaxation techniques for stress reduction.

Using relaxation techniques for stress reduction is generally considered safe and beneficial. Techniques such as deep breathing, meditation, and progressive muscle relaxation can help reduce stress and anxiety without significant risks. Therefore, this information does not require immediate investigation.

Choice B Reason:

Expresses an interest in yoga to improve flexibility.

Expressing an interest in yoga to improve flexibility is also generally safe and beneficial. Yoga can enhance physical flexibility, strength, and mental well-being. Unless the client has specific health conditions that might be affected by certain yoga poses, this information does not require immediate investigation.

Choice C Reason:

Has tried acupressure for pain relief several years ago.

Trying acupressure for pain relief several years ago is not typically a cause for concern. Acupressure is a non-invasive therapy that can help alleviate pain and promote relaxation. Since it was used in the past and not currently, it does not require immediate investigation.

Choice D Reason:

Has been using herbal supplements without consulting a healthcare provider.

This is the correct response. Using herbal supplements without consulting a healthcare provider can be risky because some supplements can interact with prescribed medications or have side effects. It is crucial for the nurse to investigate this information immediately to ensure the client’s safety and prevent potential adverse effects.

Choice A Reason:

“You should share this thought with your psychiatrist.”

This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.

Choice B Reason:

“I can make that promise to you based on nurse-client privilege.”

This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.

Choice C Reason:

“Those kinds of thoughts will make your hospitalization longer.”

This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.

Choice D Reason:

“I cannot promise that. Confidentiality does not include plans to hurt others.”

This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.