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    Hesi rn compass 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

    Choice A rationale Disagreeing with the client's delusions and setting clear limits on talking about it may cause the client to become defensive and anxious, worsening the situation. Choice B rationale Presenting a personal perception of reality in a nonconfrontational manner helps the client feel understood and supported while gently guiding them back to reality. It is an effective approach to managing delusions. Choice C rationale Agreeing with the client's delusions and asking open-ended questions reinforces the delusional thinking and may not be helpful in the long term. Choice D rationale Immediately informing the healthcare provider about the delusional episode may be necessary if the delusions pose a risk, but it does not provide immediate support to the client.

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