Psychotic Disorders no. 4058

Psychotic Disorders no. 4058

QUESTION: During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now just leave. I told you to stay home. There isn't enough work here for both of us!" What is the nurse's best initial response?

✓O a.) "When people are under stress, they may see things or hear things that others don't. Is that what just happened?"
✘O b.) "I'm having a difficult time hearing you. Please look at me when you talk."
✘O c.) "There is no one else in the room. What are you doing?"
✘O d.) "Who are you talking to? Are you hallucinating?"

RATIONALE

RATIONALE: This response makes the client feel that experiencing hallucinations is acceptable and promotes an open, therapeutic relationship. Directing the client to look at the nurse wouldn't address the obvious issue of the hallucination. Confrontational approaches, such as in options 3 and 4, are likely to elicit an uninformative or negative response.
NURSING PROCESS STEP: Implementation
CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application