A client with paranoid schizophrenia has a delusion of persecution. He tells the nurse, "The CIA is out to get me They's spying on me." The nurse's best initial response is?

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

The correct response is to explore the content of the delusion in a non-judgmental manner.
This open-ended approach acknowledges the patient's experience and the distress it is causing, without agreeing that the delusion is real.
By asking the patient to elaborate, the nurse can assess the nature of the perceived threat, the patient's level of anxiety, and any potential risk of harm.
This technique is fundamental to building a therapeutic alliance with a client who is suspicious and fearful.

Why Other Options Were Wrong

Option A: This response is defensive and introduces the concept of 'hurt,' which can be misinterpreted by a paranoid client and may escalate their fear and suspicion.
Option B: This is a confrontational question that directly challenges the patient's delusion. Challenging a fixed false belief often increases the patient's anxiety, makes them defensive, and damages the therapeutic relationship.
Option D: This response directly denies and argues with the patient's delusion. It invalidates their experience and tells them they are wrong, which can destroy trust and make them less willing to communicate.

Related Visual

Clinical Relevance

Nursing practice connection: Use the key finding related to Therapeutic communication with a patient experiencing delusions of persecution to guide bedside assessment, documentation, and the next nursing action.
The initial interaction with a client experiencing paranoid delusions is critical for establishing trust. A non-therapeutic response can shut down communication and hinder all future care.
Assessing the content of delusions is a key nursing responsibility for safety. The nurse must understand the nature of the perceived threat to determine if the client feels they need to protect themselves, which could pose a risk to self or others.
What if? If the client had said, 'The CIA is telling me to hurt myself,' the nurse's priority would immediately shift from exploring the delusion to conducting a direct suicide risk assessment and implementing safety protocols.

How to Approach the Question

First, identify the clinical scenario: a client with paranoid schizophrenia is expressing a delusion of persecution.
Next, recall the core principles of therapeutic communication for clients with psychosis. The primary goal is to build trust and assess the situation without escalating fear or anxiety.
Evaluate each option against these principles: Does it challenge the delusion? Does it argue with the client? Does it validate their feelings without confirming the delusion?
Eliminate options that are confrontational or dismissive (challenging or arguing). These are non-therapeutic.
Select the option that uses an open-ended, exploratory approach. This demonstrates empathy, encourages the client to share more, and allows the nurse to gather important assessment data.

Concept Tested & Keywords

Concept Tested: Therapeutic communication with a patient experiencing delusions of persecution.
Stem keywords: paranoid schizophrenia, delusion of persecution, nurse's best initial response
Lead-in keywords: best initial response
Clinical cues: The patient's statement 'The CIA is out to get me' indicates a delusion of persecution, which is a fixed, false belief involving themes of being attacked, harassed, or conspired against.

Question ID

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Reference Book

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 74-76

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 3273-3275

E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 1 (pp 26-289 of 579) p. 199-201

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