A nurse is caring for a client who has been diagnosed with schizoaffective disorder. The client states, 'I am the president of the United States.' Which of the following responses should the nurse make?

Correct Answer: C

Rationale: The correct response is **C: "Why do you think you are the president?"** This approach aligns with therapeutic communication techniques, particularly when working with clients experiencing delusions, as it neither directly challenges the belief nor reinforces it. Instead, it encourages the client to explore their thoughts, which can provide insight into their cognitive distortions and emotional state. This open-ended question allows the nurse to assess the severity of the delusion, identify potential triggers, and build rapport by showing genuine interest in the client's perspective without judgment. **A: "You are not the president. You are a client in the hospital."** This response is incorrect because it directly confronts the client’s delusion, which is likely to provoke defensiveness, agitation, or further withdrawal. Challenging delusional beliefs outright can damage the therapeutic relationship and escalate distress. Instead of fostering trust, this approach may reinforce the client's sense of being misunderstood or persecuted, exacerbating their symptoms. Therapeutic communication requires validating the client’s feelings without endorsing the delusion, which this response fails to achieve. **B: "Tell me more about being the president."** While this response may seem non-confrontational and exploratory, it risks reinforcing the delusion by engaging with it as though it were reality. Encouraging elaboration on a false belief can deepen the client’s preoccupation with it, making it harder to address later. The nurse should acknowledge the client’s feelings (e.g., "I hear that you feel important") without validating the delusional content. This response could inadvertently prolong or intensify the distorted thinking. **D: "Let's talk about something else."** This response avoids addressing the delusion altogether, which misses an opportunity to understand the client’s thought process and provide support. Redirecting too abruptly may make the client feel dismissed or unheard, potentially increasing their frustration or isolation. While distraction can sometimes be useful in de-escalating distress, it should not replace efforts to explore and address the underlying concerns contributing to the delusion. In contrast, **C** strikes a balance by neither validating nor dismissing the delusion. It invites the client to reflect, which can help the nurse gather clinically relevant information while maintaining a supportive and nonjudgmental stance. This approach aligns with evidence-based practices for managing psychotic symptoms, where the goal is to reduce distress rather than immediately correct the belief. By exploring the client's reasoning, the nurse can identify themes (e.g., grandiosity, paranoia) that may inform treatment planning and interventions. Additionally, this technique fosters a collaborative relationship, which is critical for long-term engagement and recovery. The incorrect choices either disrupt therapeutic rapport (A), risk reinforcing the delusion (B), or neglect the opportunity for meaningful assessment and intervention (D). **C** remains the most clinically appropriate because it prioritizes empathy, assessment, and the gradual exploration of distorted thinking without confrontation or avoidance. This method is consistent with psychiatric nursing principles that emphasize meeting the client where they are while gently guiding them toward reality-based thinking over time.

Correct Answer: B

Rationale: During a manic episode, individuals with bipolar disorder may be easily overstimulated. Placing the client in a private room to decrease environmental stimuli is the priority intervention. This action can help reduce the risk of exacerbating manic symptoms and promote a calmer environment for the client. Choice A is not the priority as group therapy may be overwhelming during a manic episode. Choice C could potentially increase stimulation rather than decrease it. Choice D should not be the first action as sedatives are generally not the initial intervention for managing manic episodes.

Correct Answer: C

Rationale: Individuals with generalized anxiety disorder commonly exhibit symptoms like excessive worry, restlessness, and difficulty concentrating. Physical manifestations such as muscle tension and sleep disturbances are also prevalent. Shortness of breath and chest pain are more commonly associated with panic attacks rather than generalized anxiety disorder. Decreased appetite may be present in some cases, but excessive worry is a hallmark characteristic of generalized anxiety disorder.

Correct Answer: A

Rationale: Encouraging the client to participate in daily activities is crucial in managing schizophrenia. Engaging in activities can enhance the quality of life and reduce symptoms by providing structure, routine, and social interaction, which are beneficial for individuals with schizophrenia. Choices B, C, and D are not the most appropriate instructions for managing schizophrenia. While expressing feelings can be helpful, daily activities have a more significant impact on managing the condition. Avoiding caffeine and spending time alone are not directly related to managing schizophrenia and may not be the most beneficial strategies.

Correct Answer: A

Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.