A nurse is sitting with a client in the dayroom. The client jumps up and states, "There are snakes coming toward me!" Which of the following responses should the nurse make?

A. "What do you usually do when this happens?": While exploring coping strategies can be helpful, this response does not immediately address the client’s distress or provide reassurance. The client may remain frightened without acknowledgment of their current experience. B. "Let's move to a different room to avoid the snakes.": Suggesting action to avoid a hallucination reinforces the false perception and can increase confusion or anxiety. It does not help the client differentiate between reality and hallucination. C. "I understand that you're seeing snakes, but I don't see any.": This response acknowledges the client’s experience without validating the hallucination as reality. It provides support and reality orientation, helping reduce anxiety and maintain a therapeutic presence. D. "Would you like to play cards?": Offering a distraction can be useful after addressing the hallucination, but initially ignoring the client’s immediate distress may make them feel unheard and unsafe. Immediate acknowledgment is a higher priority.