HESI RN Exit VI 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. Agreeing with the delusions can reinforce the false beliefs and is not an effective therapeutic approach.B. Disagreeing and setting limits may escalate the client's anxiety or agitation and does not address the delusion in a therapeutic manner.C. While informing the provider is important, the immediate action should focus on therapeutic communication with the client.D. Presenting a personal perception of reality in a non-confrontational manner helps the client to gently challenge their delusion and encourages a more grounded conversation.
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