A patient experiencing psychosis tells the nurse, "I am in charge. Who are you and why are you here?" What is the most therapeutic response by the nurse?
1. "You know who I am."
2. "You don't know who I am?"
3. "You are not in charge; you are a patient in the hospital."
4. "I am your nurse and I will be here to help you until dinner."
Answer: 4
Explanation: Responding with "I am your nurse" is an example of giving information; the nurse responds to the patient's request without getting into a confrontation and conveys respect. Asking if the patient knows who the nurse is or stating that the patient knows the nurse are not therapeutic responses and may be perceived as challenging to the patient. Stating that the patient is not in charge and reminding the patient of his or her inpatient status provide the patient with information and presents reality but do not provide the patient with a response to the question asked.
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