# Situation: A nurse at a Rural Health Unit (RHU) who uses the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) cares for a 23-year-old man with a first episode of psychosis. Before treatment he had heard voices and believed his neighbors were poisoning his food for 3 weeks. Physical causes, substance use, and mania were ruled out, and oral haloperidol was started at a low dose. At the first home visit after treatment starts, he stays at the doorway, answers in single words, and says the nurse may be working with the neighbors. What should the nurse do to begin building the relationship?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630101  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A nurse at a Rural Health Unit (RHU) who uses the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) cares for a 23-year-old man with a first episode of psychosis. Before treatment he had heard voices and believed his neighbors were poisoning his food for 3 weeks. Physical causes, substance use, and mania were ruled out, and oral haloperidol was started at a low dose.

At the first home visit after treatment starts, he stays at the doorway, answers in single words, and says the nurse may be working with the neighbors. What should the nurse do to begin building the relationship?

## 보기

1. Wait until the medicine lessens his suspicion before visiting
2. Keep visits short and arrive exactly at the times promised **✔ 정답**
3. Explain that the neighbors are not involved, to earn his trust
4. Share details of the nurse's family so he sees the nurse as a friend

**정답: 2**

## 해설

Trust is the first task of the orientation phase, and with a suspicious client it grows from consistency and reliability: brief, predictable contacts and promises that are kept. Arguing with his beliefs, withdrawing, or blurring professional boundaries would each undermine that trust.

## 심화 해설

Core issue

The client is in the orientation phase of the nurse–client relationship, but his active persecutory delusion—that the nurse may be working with the neighbors—makes him guarded and mistrustful. The priority is not to resolve the delusion, but to create conditions in which trust can begin to develop.

Why option 2 is correct

With a suspicious client, trust is built through consistency and reliability rather than through verbal persuasion or emotional closeness. Keeping visits short reduces the intensity of the interaction and lowers the client’s perceived threat. Arriving exactly at the times promised demonstrates that the nurse is predictable and keeps commitments—an early, concrete signal that the nurse is not aligned with the persecutory narrative. In the qualitative literature on paranoia, suspiciousness and mistrust are often rooted in a sense of unpredictability and threat in the social world [1]. A nurse who is brief and punctual provides a corrective relational experience: the client can observe that the nurse’s behavior matches what was said, without being pressured to abandon his beliefs.

Why the other options are incorrect

| Option | Problem | Effect on trust |
| --- | --- | --- |
| 1. Wait until the medicine lessens his suspicion before visiting | Withdrawing care delays engagement and may be interpreted as abandonment or confirmation that the nurse is not safe | Undermines trust; the client is left alone with his fears |
| 3. Explain that the neighbors are not involved | Directly challenging a fixed persecutory belief is rarely effective and can increase defensiveness | Client may feel invalidated or conclude the nurse is part of the conspiracy |
| 4. Share details of the nurse’s family | Blurs professional boundaries and shifts the focus away from the client’s needs | Creates confusion about the nurse’s role rather than genuine trust |

Clinical reasoning for the licensure exam

In a first episode of psychosis, the early treatment period is a high-risk window for medication non-adherence. A systematic review of first episode psychosis found that non-adherence is common and is shaped by the person’s attitudes, beliefs, and the quality of the therapeutic relationship . A client who believes the nurse may be colluding with the neighbors is unlikely to accept medication or follow-up if the relationship feels coercive or unpredictable. Therefore, the nurse’s immediate task is to establish a minimal but reliable relational foundation—short, punctual, non-confrontational visits—so that adherence can be addressed later as trust grows.

Watch out! Do not argue with delusions or try to “prove” you are trustworthy through self-disclosure. Key point! In the orientation phase with a paranoid client, consistency of behavior—not explanation—is the primary trust-building intervention.References (research sources)

- [1]The Lived Experience of Paranoia: Systematic Review of Qualitative Studies.Meta-analysis/systematic reviewMuscettola A, Drusiani G, Desenzani M, Belluardo L, De Bellis GA, Bortolotti L, Montemitro C, Escelsior A, Zerbinati L, Toffanin T, Caruso R, Nanni MG, Grassi L, Belvederi Murri M. (2026) · DOI: 10.1093/schizbullopen/sgag027

## 임상 시나리오

Building Trust in First-Episode PsychosisBrief, predictable contacts with a suspicious client
In the orientation phase, the first task is trust. With a client experiencing persecutory delusions, trust grows from consistency and reliability, not from verbal persuasion or emotional closeness.

Keep visits short to reduce perceived threat and arrive exactly at the times promised. This lets the client observe that the nurse's behavior matches what was said, without pressure to abandon his beliefs.

CautionDo not argue with the delusion, withdraw visits, or share personal family details. Challenging beliefs increases defensiveness, withdrawal may feel like abandonment, and self-disclosure blurs professional boundaries.

## 핵심 개념

- **Orientation phase** — The first phase of the nurse-client relationship in which trust and rapport are established before deeper therapeutic work begins.
- **Persecutory delusion** — A fixed false belief that one is being harmed, watched, or conspired against by others.
- **mhGAP-IG** — WHO Mental Health Gap Action Programme Intervention Guide for non-specialist health settings.
- **Therapeutic relationship** — A professional, goal-directed alliance between nurse and client that supports treatment and recovery.
- **Consistency and reliability** — Predictable behavior and kept promises that help a suspicious client perceive the nurse as safe and trustworthy.

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