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Difficulty: Very hardSensory and Perceptual Alterations

A home health practical nurse (PN) visits an older adult client who has advanced macular degeneration and bilateral presbycusis. The client was prescribed a new anticholinergic medication two days ago. Upon arrival, the PN observes the client swatting frantically at the air, highly distressed, and stating, "I need to get these spider webs off me before they bite!" The client's skin is notably warm and flushed. Which of the following immediate actions should the PN take? Select all that apply.

  1. Approach the client slowly from the front within their remaining field of vision while speaking in a clear, low-pitched voice.Answer
  2. Acknowledge the client's severe distress while calmly stating that the nurse does not see or feel any spider webs.Answer
  3. Obtain a complete set of vital signs and gather focused data regarding the recent medication change to report to the supervising registered nurse.Answer
  4. D
    Help the client brush the imaginary webs off their arms to rapidly build trust and alleviate immediate anxiety.
  5. E
    Attempt to logically convince the client that it is impossible for spider webs to suddenly appear indoors to orient them to reality.
  6. F
    Document the hallucinations and confusion as an expected progression of the client's severe sensory deprivation and advanced age.

Answer

The correct actions involve safely approaching the client considering their specific sensory deficits, presenting reality while validating emotions, and collecting physiological data for suspected delirium.
The correct interventions address the client's baseline sensory deficits safely, utilize therapeutic communication by validating emotion while presenting reality, and recognize the critical need for physiological data collection due to signs of acute anticholinergic delirium.

Step-by-Step Solution

1
Identify the client's baseline sensory deficits (macular degeneration and presbycusis) and modify the physical approach to prevent startling them.
The nurse must approach from the front and use a low-pitched voice.
Sudden movements or high-pitched sounds can trigger further panic in a client with compromised sensory input.
2
Analyze the client's psychological state and formulate a therapeutic response.
The nurse validates the fear but presents reality regarding the spider webs.
Arguing escalates crisis, while playing along reinforces hallucinations. Presenting reality is the safest therapeutic approach.
3
Synthesize the recent medication history (anticholinergic) with new physical findings (warm, flushed skin and hallucinations) to recognize a potential medical emergency.
The nurse prioritizes obtaining vital signs and reporting to the RN.
Acute confusion and hallucinations in older adults often indicate delirium from physiological causes (e.g., medication toxicity), requiring immediate medical evaluation.

Key Concept

Sensory and Perceptual Alterations
Estimated Time:2m 0s
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Topics

Sensory and Perceptual Alterations

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