A nurse is sitting with a client in the dayroom. The client jumps up and states, 'There are snakes coming toward me!' Which of the following responses should the nurse make?

A nurse is sitting with a client in the dayroom. The client jumps up and states, 'There are snakes coming toward me!' Which of the following responses should the nurse make?

• A. Let's move to a different room to avoid the snakes.
• B. What do you usually do when this happens?
• C. I understand that you're seeing snakes, but I don't see any.
• D. Would you like to play cards?

Answer: (C)

When a client reports perceptual disturbances like seeing snakes, the nurse should respond in a way that acknowledges the experience without arguing about its reality. This approach—validating what the client is experiencing while maintaining safety and a calm, nonjudgmental tone—helps reduce fear and builds trust. Saying, “I understand you’re seeing snakes, but I don’t see any,” does exactly that: it confirms the client’s distress, avoids confrontation, and opens the door for further exploration and support. It also signals that the nurse is present and will stay with the client, which can help stabilize the situation. Moving to a different room doesn’t address the immediate experience and can unintentionally validate the perception or make the client feel isolated. Asking what the client usually does when this happens is a useful follow-up in exploring coping strategies, but it’s not the best first response to acknowledge the current perception. Offering to play cards ignores the distress and can feel dismissive.

When a client reports perceptual disturbances like seeing snakes, the nurse should respond in a way that acknowledges the experience without arguing about its reality. This approach—validating what the client is experiencing while maintaining safety and a calm, nonjudgmental tone—helps reduce fear and builds trust. Saying, “I understand you’re seeing snakes, but I don’t see any,” does exactly that: it confirms the client’s distress, avoids confrontation, and opens the door for further exploration and support. It also signals that the nurse is present and will stay with the client, which can help stabilize the situation.

Moving to a different room doesn’t address the immediate experience and can unintentionally validate the perception or make the client feel isolated. Asking what the client usually does when this happens is a useful follow-up in exploring coping strategies, but it’s not the best first response to acknowledge the current perception. Offering to play cards ignores the distress and can feel dismissive.