A client is pacing in the hall. The nurse overhears the client say, "Leave me alone. I am not in the Mafia." The best response from the nurse would be:
1. "Remember you are safe from the Mafia here in the hospital."
2. "Tell me what you are hearing right now."
3. "You need to attend the next recreation group. That will help you ignore the voices."
4. "You are hearing voices again, right?"
2
Rationale: "Tell me what you are hearing right now" is an open statement that allows the client to inform the nurse what is being experienced. The nurse does not presume to know what the client is experiencing. "You are hearing voices again, right?" presumes to know what the client is experiencing without asking the patient directly. "You need to attend the next recreation group. That will help you ignore the voices" does not ask for an explanation of the client's experiences and implies that a client can ignore voices. "Remember you are safe from the Mafia here in the hospital" does not ask for an explanation of the client's experiences, so may not be addressing the client's needs at this time. This is an example of false reassurance.
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