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Difficulty: MediumSensory and Perceptual Alterations

The practical nurse (PN) is caring for a 68-year-old client who has been in a private room on contact precautions for five days. The client suddenly points upward, appears visibly frightened, and states, 'The people on the ceiling are whispering to me.' Which actions should the PN take to support this client? Select all that apply.

  1. State that the voices are not real while acknowledging the client's feelings of fear.Answer
  2. B
    Apply bilateral soft wrist restraints to ensure the client does not leave the isolation room.
  3. Ensure the room has adequate lighting and open the window blinds during daylight hours.Answer
  4. Place a large-faced clock and the current calendar directly in the client's line of sight.Answer
  5. E
    Pretend to speak to the people on the ceiling and firmly ask them to leave the room.
  6. F
    Attribute the perceptual alteration to the normal aging process and document the findings.

Answer

The correct actions involve presenting reality, acknowledging the client's fear, providing appropriate environmental lighting, and promoting reorientation with a clock and calendar.
For a client experiencing sensory deprivation and hallucinations, the practical nurse must prioritize safety, reorientation, and therapeutic communication. Acknowledging the client's fear while gently presenting reality helps build trust without reinforcing the false perception. Optimizing the environment with adequate lighting reduces shadows that can contribute to illusions or hallucinations. Providing concrete orienting tools, such as a clock and calendar, helps ground the client in reality.

Step-by-Step Solution

1
Analyze the client's presentation.
The client is experiencing a visual and auditory hallucination, likely triggered by sensory deprivation from prolonged isolation.
Identifying the root cause of the perceptual alteration guides appropriate nursing interventions.
2
Determine therapeutic communication strategies.
The nurse must validate the client's fear without reinforcing the hallucination.
Arguing with the client or playing into the hallucination increases agitation, whereas presenting reality builds trust.
3
Identify environmental modifications.
Increasing natural light and providing orienting tools (clock, calendar) should be implemented.
These modifications combat sensory deprivation and help ground the client in reality.

Key Concept

Sensory Deprivation and Hallucination Management
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Topics

Sensory and Perceptual Alterations

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