Question

question 2 of 75

an adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. she tells the nurse, \please let me go! i must leave because the secret police are after me.\ which response is best for the nurse to make?

no one is after you, youre safe here.
youll feel better after you have rested.
i know you must feel lonely and frightened.
come with me to your room and i will sit with you.

Explanation:

Analyze the client's presentation and underlying needs

The client is experiencing a persecutory delusion ("the secret police are after me") accompanied by physical restlessness and an attempt to elope from the unit, indicating high anxiety and a perceived threat to safety.

Evaluate the therapeutic communication of each option

• "No one is after you, you're safe here": Directly challenges the delusion, which can increase anxiety and defensiveness.
• "You'll feel better after you have rested": Dismisses the client's immediate terror and offers false reassurance.
• "I know you must feel lonely and frightened": Addresses feelings but does not offer a concrete, safe intervention to manage the immediate physical restlessness and elopement risk.
• "Come with me to your room and I will sit with you": Offers a quiet, low-stimulus environment to reduce restlessness, ensures safety, and provides therapeutic presence ("I will sit with you") without validating or challenging the delusion.

Answer:

• No one is after you, you're safe here.
• You'll feel better after you have rested.
• I know you must feel lonely and frightened.
• Come with me to your room and I will sit with you. (Correct answer)