The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?
Explanation & Rationale
A. Attempt to comfort the client by agreeing with the delusions and ask open-ended questions: Agreeing with delusions reinforces false beliefs and can interfere with therapeutic communication and trust-building. B. Disagree with the statement and set clear limits on talking about it: Directly challenging or confronting delusions can make the client defensive or agitated, damaging the therapeutic relationship. C. Immediately inform the healthcare provider that the client is experiencing a delusional episode: While documentation and provider notification may be needed later, the immediate priority is to respond therapeutically to the client’s current perception. D. Present a personal perception of reality in a nonconfrontational manner: Gently presenting an alternative view without challenging the client’s experience respects the client’s perspective while maintaining a grounded, therapeutic approach to reality orientation.