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

Choice A Reason:

While this response attempts to offer support, it makes an assumption about the mother’s understanding without addressing the client’s feelings directly. Therapeutic communication should focus on validating the client’s emotions and encouraging them to express their thoughts and feelings. This response might not fully acknowledge the client’s distress.

Choice B Reason:

This response normalizes the client’s feelings, which can be helpful, but it does not directly address the client’s specific concern. While it is important to reassure the client that their feelings are common, the response should also validate their individual experience and encourage further discussion.

Choice C Reason:

Encouraging the client to talk to their mother is a proactive suggestion, but it may not be the most therapeutic initial response. The client might not be ready to take that step, and the nurse should first focus on understanding and validating the client’s feelings before suggesting actions. This response could be more appropriate as a follow-up after the client’s feelings have been explored.

Choice D Reason:

This response is the most therapeutic because it uses reflective listening to validate the client’s feelings. By restating what the client has expressed, the nurse shows empathy and encourages the client to explore their emotions further. This technique helps the client feel heard and understood, which is crucial in therapeutic communication.

Choice A Reason:

Pseudo-Parkinsonian side effects, also known as drug-induced parkinsonism, can occur with the use of antipsychotic medications like haloperidol. These side effects include symptoms such as rigidity, bradykinesia, tremor, and postural instability. However, the description of the client’s neck arched sharply backward is more indicative of an acute dystonic reaction rather than pseudo-Parkinsonian side effects. Pseudo-Parkinsonian symptoms typically develop more gradually and do not present with such dramatic posturing.

Choice B Reason:

While some side effects of haloperidol can be temporary and may disappear after several days, the acute dystonic reaction described in the scenario requires immediate intervention. Acute dystonic reactions are characterized by sudden, severe muscle contractions that can be painful and potentially dangerous if they involve the airway. Therefore, it is crucial to address this reaction promptly rather than waiting for it to resolve on its own.

Choice C Reason:

Increasing the dosage of haloperidol in response to the described symptoms would likely exacerbate the situation. The client’s symptoms are not indicative of worsening psychotic behavior but rather an adverse reaction to the medication. Increasing the dosage could lead to more severe side effects and complications. The appropriate response is to treat the acute dystonic reaction and reassess the medication regimen.

Choice D Reason:

An acute dystonic reaction is a known side effect of antipsychotic medications like haloperidol. It involves sudden, severe muscle contractions, often affecting the neck, face, and back. This reaction can be distressing and requires immediate treatment with anticholinergic medications such as benztropine or diphenhydramine. Prompt intervention can relieve the symptoms and prevent further complications.