Question

an adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. which response is best for the nurse to provide?

you are in the hospital, and i am the nurse caring for you.
it must be difficult for you to control your anxious feelings.
go to occupational therapy and start a project.
you are not in a war area now; this is the united states.

Explanation:

Analyze the client's presentation

The client is presenting with a persecutory/somatic delusion (microchips planted in his head for military surveillance).

Evaluate therapeutic communication principles for delusions

When communicating with a client experiencing delusions:

• Do not argue with, challenge, or validate the delusion (ruling out "You are not in a war area now; this is the United States").
• Do not dismissively redirect without acknowledging the client's feelings or reality (ruling out "Go to occupational therapy and start a project").
• Focus on the feelings underlying the delusion, or gently present reality without arguing.
• "You are in the hospital, and I am the nurse caring for you" is a therapeutic response that presents reality, establishes the nurse-client relationship, and provides a safe, orienting environment.
• "It must be difficult for you to control your anxious feelings" focuses on feelings but assumes the client is trying to "control anxious feelings," which may not be the primary issue or may sound slightly patronizing compared to establishing immediate safety and reality. Presenting reality and offering self/orientation is the foundational first step.

Select the best response

The response "You are in the hospital, and I am the nurse caring for you" provides reality orientation and a safe environment, which is the priority intervention for a client experiencing active delusions.

Answer:

• (A) You are in the hospital, and I am the nurse caring for you. (Correct answer)
• (B) It must be difficult for you to control your anxious feelings.
• (C) Go to occupational therapy and start a project.
• (D) You are not in a war area now; this is the United States.