# A nurse is caring for a client with schizophrenia who has been experiencing auditory hallucinations and paranoid delusions. The client suddenly becomes agitated and states, "The voices are telling me that you're trying to poison me with that medication!" What is the most therapeutic nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543379 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a client with schizophrenia who has been experiencing auditory hallucinations and paranoid delusions. The client suddenly becomes agitated and states, "The voices are telling me that you're trying to poison me with that medication!" What is the most therapeutic nursing intervention? ## 보기 1. Tell the client, "The voices are not real. You are safe here, and the medication is safe." 2. Acknowledge the client's experience and focus on feelings: "I can see this is frightening for you. I am here to help you feel safe." **✔ 정답** 3. Ask the client to describe in detail what the voices are saying about the medication. 4. Leave the room immediately and return with security personnel for safety. **정답: 2** ## 해설 Therapeutic communication involves acknowledging the client's feelings without reinforcing delusions, which builds trust and reduces agitation. Other options either confront the delusion, escalate fear, or fail to address emotional distress. ## 심화 해설 Therapeutic Communication in Acute Psychosis When a client with schizophrenia presents with command hallucinations and paranoid delusions that incorporate the nurse into a persecutory belief system, the immediate priority is de-escalation through validation of the client's emotional state without reinforcing the delusional content. This client is experiencing a severe exacerbation of psychotic symptoms, where auditory hallucinations are generating a fixed, false belief that the medication is poison and the nurse is the agent of harm. The clinical presentation reflects an acute phase of hallucinatory distress, a period during which the therapeutic relationship is both most vulnerable and most critical. The correct intervention, option 2, uses a core principle of therapeutic communication: acknowledging the client's feelings rather than the content of the hallucination. The statement "I can see this is frightening for you" validates the genuine fear the client is experiencing. This fear is a measurable physiological and psychological response to the perceived threat, even though the threat itself is not based in reality. By focusing on the emotional response, the nurse aligns with the client's subjective reality without agreeing with the delusion that the medication is poison. The second part, "I am here to help you feel safe," directly addresses the hyperarousal and mistrust that characterize the acute phase. This approach is consistent with the principles of Therapy administered by Mental Health Nurses (TKN), which is designed as a timely and effective intervention to comprehensively address acute hallucinatory symptoms. The goal is to alleviate the distress associated with the hallucination, creating a foundation for safety and further therapeutic engagement. Analysis of Incorrect Options Option 1 ("The voices are not real. You are safe here, and the medication is safe.") is non-therapeutic because it directly challenges the client's delusional belief. During an acute psychotic episode, the client lacks the insight to distinguish hallucinations from reality. Arguuing with the delusion or presenting reality-based logic often escalates agitation, as the client perceives the nurse as either lying or being part of the conspiracy. This approach undermines trust at a critical moment. Option 3 (Asking the client to describe the voices in detail) is contraindicated during acute agitation. Probing for detailed content of command hallucinations, especially those with persecutory themes, can intensify the client's preoccupation with the delusion and increase distress. This type of exploration is more appropriate after the acute phase has resolved and the client is stabilized, not when they are actively fearful and agitated. Option 4 (Leaving the room immediately to get security) would be interpreted by the client as confirmation of their paranoid delusion—that the nurse has malicious intent and is now abandoning them or gathering forces against them. While safety is paramount, the immediate withdrawal of the nurse without any verbal de-escalation attempt can rupture the therapeutic relationship and increase the client's terror and potential for behavioral escalation. De-escalation through verbal intervention should be the first-line approach, with security as a supportive measure if the situation deteriorates, not as an initial, silent retreat. The TKN framework emphasizes that in the context of acute psychiatric care with severe hallucinatory symptoms, the nurse's therapeutic presence and targeted communication are interventions in themselves. The effectiveness of such nursing therapy lies in its ability to alleviate the immediate symptoms of hallucination by first addressing the intense emotional dysregulation that accompanies them. By recognizing the client's fear and offering a non-threatening, supportive presence, the nurse begins the process of guiding the client from a state of acute psychotic terror toward a state of perceived safety. ## 임상 시나리오 Managing Acute Psychosis with Paranoid DelusionsDe-escalation through therapeutic validation When a client incorporates the nurse into a persecutory delusion, the immediate goal is de-escalation. Acknowledge the emotional reality of fear without agreeing with the false belief. This maintains the therapeutic alliance. Use statements that focus on the client's feelings and offer support, such as "I can see this is frightening for you. I am here to help you feel safe." This addresses the underlying hyperarousal and mistrust. CautionNever directly challenge a delusion by stating it is not real. This is perceived as a threat, increases anxiety, and can rapidly escalate agitation. Do not leave the client alone, as this confirms their paranoid belief of being dangerous. ## 핵심 개념 - **Command Hallucinations** — Auditory hallucinations that instruct the patient to perform specific acts, posing a safety risk. - **Therapeutic Communication** — Verbal and nonverbal techniques focused on the patient's needs to build trust and explore feelings. - **Delusions** — Fixed, false beliefs not based in reality and resistant to reason, common in schizophrenia. - **De-escalation** — A combination of verbal and nonverbal techniques to reduce patient agitation and prevent violence. - **Validation** — Acknowledging and accepting a patient's emotional experience without necessarily agreeing with the factual content. ## 같은 주제 문제 - [A nurse is assessing a 35-year-old client who was recently admitted to the psychiatric uni…](https://mymerci.kr/pages/nclex_q.php?qn_id=543376) - [A nurse is assessing a 35-year-old client who was recently admitted to the psychiatric uni…](https://mymerci.kr/pages/nclex_q.php?qn_id=543377) - [A nurse is caring for a client with schizophrenia who has been experiencing auditory hallu…](https://mymerci.kr/pages/nclex_q.php?qn_id=543378) - [A nurse is caring for a client with schizophrenia who has been experiencing auditory hallu…](https://mymerci.kr/pages/nclex_q.php?qn_id=543380) - [A nurse is caring for a client with bipolar disorder who has been experiencing auditory ha…](https://mymerci.kr/pages/nclex_q.php?qn_id=543381) - [A nurse is caring for a client with schizoaffective disorder who has been experiencing aud…](https://mymerci.kr/pages/nclex_q.php?qn_id=543382) - [A nurse is caring for a client with schizophrenia who has been experiencing auditory hallu…](https://mymerci.kr/pages/nclex_q.php?qn_id=543383) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._