Psychotic Disorders no. 4041

Psychotic Disorders no. 4041

QUESTION: Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

✘O a.) Dismantling the showerhead and showing the client that there is nothing in it
✘O b.) Explaining that other clients are complaining about the client's body odor
✘O c.) Asking a security officer to assist in giving the client a shower
✓O d.) Accepting these fears and allowing the client to take a sponge bath

RATIONALE

RATIONALE: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality (as in option 1) wouldn't be effective at this time. Options 2 and 3 would violate the client's rights by shaming or embarrassing the client.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application