of silence. The presence of the nurse is a contact with
reality for the client and also can demonstrate the
nurse’s genuine interest and caring to the client. Call-
ing the client by name, making references to the day
and time, and commenting on the environment are all
helpful ways to continue to make contact with a client
who is having problems with reality orientation and
verbal communication. Clients who are left alone for
long periods become more deeply involved in their psy-
chosis, so frequent contact and time spent with the
client are important even if the nurse is unsure that
the client is aware of the nurse’s presence.
Actively listening to the client is an important
skill for the nurse trying to communicate with a
client whose verbalizations are disorganized or non-
sensical. Rather than dismissing what the client says
because it is not clear, the nurse must make efforts
to determine the meaning the client is trying to con-
vey. Listening for themes or recurrent statements,
asking clarifying questions, and exploring the mean-
ing of the client’s statements are all useful tech-
niques to increase understanding.
The nurse must let the client know when his or
her meaning is not clear. It is never useful to pretend
to understand or just to agree or go along with what
the client is saying: this is dishonest and violates
trust between client and nurse.
Nurse:“How are you feeling today?” (using a
broad opening statement)
Client:“Invisible.”
Nurse:“Can you explain that to me?” (seeking
clarification)
Client:“Oh, it doesn’t matter.”
Nurse:“I’m interested in how you feel; I’m just not
sure I understand.” (offering self/seeking clarification)
Client:“It doesn’t mean much.”
Nurse:“Let me see if I can understand. Do you
feel like you’re being ignored, that no one is really lis-
tening?” (verbalizing the implied)
IMPLEMENTING INTERVENTIONS FOR
DELUSIONAL THOUGHTS
The client experiencing delusions utterly believes
them and cannot be convinced that they are false or
untrue. Such delusions powerfully influence the
client’s behavior. For example, if the client’s delusion
is that he or she is being poisoned, he or she will be
suspicious, mistrustful, and probably resistant to
providing information and taking medications.
The nurse must avoid openly confronting the
delusion or arguing with the client about it. The nurse
also must avoid reinforcing the delusional belief by
“playing along” with what the client says. It is the
nurse’s responsibility to present and maintain reality
by making simple statements such as “I have seen no
evidence of that”(presenting reality) or “It doesn’t
seem that way to me”(casting doubt). As antipsychotic
medications begin to have a therapeutic effect, it will
be possible for the nurse to discuss the delusional
ideas with the client and identify ways in which the
delusions interfere with the client’s daily life.
The nurse also can help the client minimize the
effects of delusional thinking. Distraction techniques,
such as listening to music, watching television, writ-
ing, or talking to friends, are useful. Direct action,
such as engaging in positive self-talk and positive
thinking and ignoring the delusional thoughts, may
be beneficial as well (Murphy & Moller, 1993).IMPLEMENTING INTERVENTIONS
FOR HALLUCINATIONS
Intervening when the client experiences hallucina-
tions requires the nurse to focus on what is real and
to help shift the client’s response toward reality. Ini-
tially the nurse must determine what the client is
experiencing—that is, what the voices are saying or
what the client is seeing. Doing so will increase the
nurse’s understanding of the nature of the client’s
feelings and behavior. In command hallucinations,
the client hears voices directing him or her to do
something, often to hurt self or someone else. For
this reason, the nurse must elicit a description of the
content of the hallucination so that health care per-
sonnel can take precautions to protect the client and
others as necessary. The nurse might say, “I don’t
hear any voices; what are you hearing?”(presenting
reality/seeking clarification). This also can help the
nurse understand how to relieve the client’s fears or
paranoia. For example, the client might be seeing
ghosts or monster-like images, and the nurse could
respond: “I don’t see anything, but you must be fright-
ened. You are safe here in the hospital”(presenting
reality/translating into feelings). This acknowledges
the client’s fear but reassures the client that no harm
will come to him or her.
Clients do not always report or identify halluci-
nations. At times the nurse must infer from the client’s
behavior that hallucinations are occurring. Exam-
ples of behavior that indicate hallucinations include
alternately listening and then talking when no one
else is present, laughing inappropriately for no ob-
servable reason, and mumbling or mouthing words
with no audible sound.
A helpful strategy for intervening with halluci-
nations is to engage the client in a reality-based ac-
tivity such as playing cards, engaging in occupational
therapy, or listening to music. It is difficult for the
client to pay attention to hallucinations and reality-314 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS