The nurse is talking with a male client who is actively hallucinating. The client is fearful that the voices he hears will direct him to kill himself or will hurt him directly
Which of the following nursing statements would be therapeutic at this time? 1. "I can hear the voices too, but they are telling you to go to bed now."
2. "I know whose voices you are hearing and told them not to hurt you."
3. "I know you believe they are going to cause you harm, but it's not true."
4. "I don't hear them, but it must be frightening to hear voices that others can't hear."
4
Rationale: It is important for the nurse to let the client know that what the client is hearing is not heard by the nurse and to avoid reinforcing the client's altered reality. The nurse avoids con-fronting the client but rather says supportive things such as, "This must be very frightening to you" or "It's difficult to understand all that you are experiencing right now." "I can hear the voices too, but they are telling you to go to bed now." "I know whose voices you are hearing and told them not to hurt you." and "I know you believe they are going to cause you harm, but it's not true." reinforce the client's altered reality.
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