A delusional client has refused to eat for the past 24 hours because, he says, "the food is
poisoned." How should the nurse respond?
1
"Why do you think that the food is poisoned?"
Correct2
"You feel worried that so
...
A delusional client has refused to eat for the past 24 hours because, he says, "the food is
poisoned." How should the nurse respond?
1
"Why do you think that the food is poisoned?"
Correct2
"You feel worried that someone wants to poison you?"
3
"This feeling is a symptom of your illness. It's not real."
4
"You'll be safe with me. I won't let anyone poison you."
It is important to help the client focus on feelings, and "You feel worried that someone wants to
poison you?" is the only response that helps achieve this goal. Why questions call for a
conclusion rather than an exploration of the issue; the client may not have the answer. Although
stating that the feeling is a symptom of the client's illness is true, it is not something that the
client is ready to understand; also, it is a closed statement. "You'll be safe with me. I won't let
anyone poison you" is false reassurance and is not realistic; the client still is concerned about
what will happen when the nurse is not there.
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22.
A client on the psychiatric unit tells the nurse, "The voices have told me that I'm in danger. They
say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks
between the floor tiles." What is the best initial response by the nurse?
1
"Don't worry. You're safe here. Are you afraid that I'll let someone hurt you?"
Correct2
"I know that these voices are real to you, but I want you to know that I don't hear them."
3
"Tell me more about the voices. Are they male or female? How many voices do you hear?"
4
"You need to leave this room and get your mind occupied so the voices don't bother you
anymore."
"I know that these voices are real to you, but I want you to know that I don't hear them"
demonstrates recognition and acceptance of the client's feelings and also points out reality.
"Don't worry. You're safe here. Are you afraid that I will let someone hurt you?" provides false
reassurance; the client has no reason to trust that the nurse can provide protection. Focusing on
the content of the delusion will reinforce the delusion. Encouraging the client to focus on
hallucinations tends to strengthen and confirm them. "You need to leave this room and get yourmind occupied so the voices don't bother you anymore" denies the client's feelings and may
increase anxiety.
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