50. A client whispers, "The spiders are coming out of the vents; we need to move." Which response by a nurse demonstrates the therapeutic technique of focusing on reality?
50. A client whispers, "The spiders are coming out of the vents; we need to move." Which response by a nurse demonstrates the therapeutic technique of focusing on reality?
. "I didn't understand you. Can you repeat that?"
. "That's strange. I don't see any spiders."
. "What did you see?"
. "That must be frightening to think that."
Test-Taking Tip
Choose feedback (Answer 2) before feelings (Answer 4) or before facts (Answer 3) or feedback by nurse and request for repetition by client (Answer 1). Think of the three "Fs": feedback, then feelings, then fact.
Content Area: Mental Health, Therapeutic Communication; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Sensory/Perceptual Alterations
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Answer 1 is incorrect because the nurse is using the technique of giving feedback and asking for restatement, which is not therapeutic at this time because the client needs reality orientation first. Answer 2 is correct because the nurse is expressing doubt about an unreal perception. Answer 3 is incorrect because the nurse is encouraging clarification of an experience before providing reality orientation, which then needs to be followed by acknowledgement of the client's feelings. Answer 4 is incorrect because the nurse needs to first provide reality orientation, not focus on feelings.