The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the bestresponse by the nurse?

Question

Quizplus · Accepted Answer

An important step toward self-management of hallucinationsis for the client to recognize that the hallucinations are not real. When a client is experiencing hallucinations, the nurse needs to reinforce realityand acknowledgehow the client may be feeling. The nurse can point out his/her own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit." Examples of additional therapeutic responses to a client who is experiencing hallucinations include the following: "I don't see anything, but I understand that what you are seeing may be very upsetting to you." "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." "I know the voices seem real to you and may be scary. I do not hear the voices." (Option B) This response reinforces the hallucination and does not present reality to the client. (Option C) This response ignores what the client is experiencing and does nothing to reduce the client's feeling of discomfort. (Option D) This response provides an explanation for the client's experience but does not acknowledge the client's feelings or reinforce reality. Educational objective: The most therapeutic response to a client experiencing hallucinations presents reality and acknowledges how the client may be feeling. This approach promotes self-management by helping the client recognize that the hallucinations are not real.

The Nurse Is Caring for a Client with Schizophrenia Who