Difficulty: Medium
Average Score: 91%
Full-length
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
Correct answer
A
Rationale
The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.