Question: The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client? Select all that apply.
1. Use active listening skills to seek information from the client.
2. Encourage the client to describe the problem as she sees it.
3. Ask the client to tell you exactly what she thinks is happening.
4. Tell the client that she is delusional and you can help her.
5. Explain to the client that most people are not investigated by the CIA or FBI.
6. Reassure the client that you are not with the CIA.
Answer: 1, 2, 3
Rationale: The client is demonstrating paranoid behavior, which necessitates a matter-of-fact approach that is nonjudgmental and accepting of the client's statements and shows the nurse's willingness to listen attentively to the issue. Options 4, 5, and 6 do not help the paranoid client gain trust to talk with the nurse.
This week's NCLEX exam practice question is brought to you by:
Zerwekh: Illustrated Study Guide for the NCLEX-RN Exam, 7th edition, Chapter 9, Page 164 Question 7
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