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Difficulty: MediumSensory and Perceptual Alterations

An older adult client with a history of chronic obstructive pulmonary disease (COPD) is assigned to a bed located directly across from the busy central nursing station. After three days of constant exposure to telemetry alarms, overhead pages, and staff conversations, the client becomes increasingly restless, disoriented to time, and states they see insects crawling on the walls. Which actions should the practical nurse (PN) take to address this client's sensory alteration? Select all that apply.

  1. Group required assessments and medication administrations together to minimize interruptions.Answer
  2. B
    Tell the client, "You have nothing to worry about; there are no insects in this room."
  3. Dim the overhead lights and close the door partially to decrease external stimuli.Answer
  4. D
    Record the onset of hallucinations as an expected progression of age-related cognitive decline.
  5. Reorient the client to their surroundings using a calm, unhurried voice.Answer
  6. F
    Apply bilateral soft wrist restraints to prevent the client from removing their oxygen tubing during periods of agitation.

Answer

The correct interventions are grouping care tasks, reducing environmental stimuli by dimming lights and closing the door, and providing calm reorientation.
The correct actions directly address sensory overload by reducing environmental stimuli (dimming lights, partially closing the door), minimizing interruptions to promote rest (clustering care), and safely managing the client's altered perception through therapeutic communication (calm reorientation).

Step-by-Step Solution

1
Analyze the client's presentation and environmental factors.
The client is exhibiting signs of sensory overload and acute delirium due to continuous noise and activity from the nearby nursing station.
Identifying the root cause (excessive environmental stimuli) dictates the appropriate nursing interventions.
2
Evaluate each intervention for safety, scope of practice, and therapeutic value.
Interventions that reduce stimuli (clustering care, dimming lights) and provide safe psychological support (calm reorientation) are selected.
These actions directly mitigate the sensory overload without causing further harm or utilizing restrictive measures.
3
Reject inappropriate or unsafe interventions.
Dismissing the client's fears, normalizing acute confusion, and applying restraints are eliminated.
These actions represent non-therapeutic communication, failure to recognize acute delirium, and premature use of restraints, all of which compromise client safety.

Key Concept

Management of Sensory Overload
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Topics

Sensory and Perceptual Alterations

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