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    HESI RN Exit Proctored ExamQuestion 127
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    HESI RN Exit Proctored Exam

    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. Disagree with the statement and set clear limits on talking about it. Disagreeing can cause conflict and worsen the delusion, making it important to use a nonconfrontational approach. B. Immediately inform the healthcare provider that the client is experiencing a delusional episode. While the provider should be informed later, the immediate action should be to address the delusion with care. C. Attempt to comfort the client by agreeing with the delusions and ask open-ended questions. Agreeing with delusions reinforces them and does not address the underlying issue. D. Present a personal perception of reality in a nonconfrontational manner. Gently correcting the client's delusion by presenting reality helps the client understand the situation without challenging their beliefs directly, which could escalate anxiety.

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