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A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he’s going to cut out my heart." The nurse’s best response is:
A. "I know you’re feeling frightened right now, but I want you to know that I don’t see anyone in the corner."
B. "You’ll probably see strange things for a while until the PCP wears off."
C. "Try to sleep. When you wake up, the devil will be gone."
D. "You’re probably feeling guilty because you used illegal drugs tonight."
Correct Answer: A
Explanation/Reference:
Explanation:
(A) The nurse is the client’s link to reality. This response validates the authenticity of the client’s experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content. (D) The nurse is making an incorrect assumption about the client’s feelings by offering a nontherapeutic interpretation of the motivation for the client’s actions.
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