A client recovering from a systemic infection on a medical-surgical unit becomes suddenly distressed at dusk. The client points toward the shadowed window curtains and shouts, "Who are those strangers trying to get inside? Make them go away!" Which action should the practical nurse (PN) take first?
- Stay with the client, turn on the room lights to reduce shadows, and offer calm reassurance.Answer
- BTell the client that there is nobody at the window and instruct them to stop shouting.
- CRequest a prescription to apply physical restraints to prevent the client from injuring themselves.
- DDocument the behavior in the chart as a normal progression of age-related cognitive decline.
Answer
Stay with the client, turn on the room lights to reduce shadows, and offer calm reassurance.
The client is experiencing a visual illusion, a sensory misperception triggered by the dim lighting and shadows of dusk, which is common in clients at risk for delirium. The priority nursing action is to modify the environment by turning on the lights to eliminate the shadows. Staying with the client ensures safety and provides therapeutic reassurance without arguing about their perceived reality.
Step-by-Step Solution
Key Concept
Sensory Alteration Management and Therapeutic Environment