A client states, "The voices say I'll be safe only if I stay in this room." What is the best initial response by the nurse?

A client states, "The voices say I'll be safe only if I stay in this room." What is the best initial response by the nurse?

• A. "I understand that these voices are real to you, but I want you to know that I don't hear them."
• B. "Just ignore the voices and focus on me."
• C. "You should try to listen to them."
• D. "That's not a real concern."

Answer: (A)

The response that acknowledges the reality of the client's experience while also asserting a boundary is the most appropriate initial response in this scenario. By stating, "I understand that these voices are real to you, but I want you to know that I don't hear them," the nurse validates the client's feelings and experience without endorsing the content of the hallucination. This approach fosters a therapeutic alliance, allowing the client to feel heard and understood, which is crucial in mental health nursing. Validation helps reduce the client's anxiety related to their experiences and can create an opportunity for further therapeutic dialogue. It also sets the stage for educating the client about their condition and exploring strategies for managing their symptoms in a supportive manner. This validates the client's feelings and promotes engagement, which is essential for building trust in the nurse-client relationship.

The response that acknowledges the reality of the client's experience while also asserting a boundary is the most appropriate initial response in this scenario. By stating, "I understand that these voices are real to you, but I want you to know that I don't hear them," the nurse validates the client's feelings and experience without endorsing the content of the hallucination. This approach fosters a therapeutic alliance, allowing the client to feel heard and understood, which is crucial in mental health nursing.

Validation helps reduce the client's anxiety related to their experiences and can create an opportunity for further therapeutic dialogue. It also sets the stage for educating the client about their condition and exploring strategies for managing their symptoms in a supportive manner. This validates the client's feelings and promotes engagement, which is essential for building trust in the nurse-client relationship.