A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?

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The client, while delusional, is exhibiting signs of anxiety. The priority action for the nurse is to intervene in a manner that will assist in reducing the client's unease. The headband is part of the client's delusional system; it is highly likely that the client will continue to be apprehensive until the headband or substitute is found. Offering to help the client look for the headband conveys a sense of caring and helps establish a trusting relationship. Once the client has calmed down, the nurse will minimize any conversation about the "crack" and the "oil" and can direct the client to reality-oriented activities. Delusions are fixed, false beliefs that are accepted by the client as real and cannot be changed by logic, reason, or persuasion. Categories of delusions include the following: Persecutory - client thinks others are "out to get me" Ideas of reference - common events refer specifically to the client Grandiose - client has the perception of special importance or powers that are not realistic Somatic - false ideas about bodily functioning Nursing interventions include the following: Not arguing or challenging the belief Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system. (Option A) This response focuses on the delusional content and is not therapeutic. It does not help alleviate the client's anxiety. (Option C) Challenging the delusional content is not therapeutic and will not change the client's belief. (Option D) This statement does not help reduce the client's anxiety. Educational objective: The priority nursing action for a client exhibiting anxiety is to intervene in a manner that helps make the client feel more at ease. Delusions are fixed, false beliefs; challenging a client's delusional content system will increase the client's anxiety and will not change the client's beliefs.

A Client with a 20-Year History of Schizophrenia Is Hospitalized