A practical nurse (PN) enters the room of a client with macular degeneration who is acutely agitated. The client is pointing at moving shapes cast by the window blinds and screaming, "Keep those snakes away from my bed!" The environment is chaotic due to multiple loud alarms sounding from the roommate's medical equipment. Arrange the following nursing actions in the priority order the PN should implement them.
- 1Verbally announce presence at the room entrance and approach the client using a calm, reassuring tone.
- 2Acknowledge the client's feelings of fear while stating clearly that the shapes are shadows, not snakes.
- 3Turn on the overhead room lights and adjust the window blinds to eliminate the moving shadows.
- 4Reduce ambient environmental noise by silencing or addressing the roommate's equipment alarms.
- 5Document the perceptual alteration episode and notify the supervising registered nurse (RN).
Answer
The correct priority sequence is to first establish a safe verbal presence, then use therapeutic communication to present reality, followed by eliminating the specific visual trigger, reducing overall sensory overload, and finally reporting the event.
In acute sensory crises involving illusions, the nursing priority sequence follows safety and Maslow's hierarchy. The nurse must first ensure safety by not startling a visually impaired client (announce presence). Next, psychological safety is established by validating fear and presenting reality. Then, the nurse addresses the specific trigger (shadows), followed by the contributing factors (loud alarms). Finally, the nurse reports the incident for continuity of care.
Step-by-Step Solution
Key Concept
Prioritization of nursing interventions for acute sensory alterations and illusions