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    HESI 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 reason: Attempting to comfort the client by agreeing with the delusions is not therapeutic and may reinforce the delusional beliefs.Choice B reason: Presenting a personal perception of reality in a nonconfrontational manner helps the client recognize reality without creating conflict or distress.Choice C reason: Disagreeing with the statement and setting clear limits may be perceived as confrontational and could increase the client's distress.Choice D reason: Informing the healthcare provider is important but should not be the immediate action. Addressing the client's delusions therapeutically is the first priority.

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