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Difficulty: EasySensory and Perceptual Alterations

While performing a room check on a medical-surgical unit, a licensed practical nurse observes a newly admitted client pointing frantically at a blank wall. The client shouts, 'Get those huge spiders away from me!' Which action should the nurse take first?

  1. State calmly that while the client appears frightened, the nurse does not see any spiders.Answer
  2. B
    Tell the client firmly that the wall is completely empty and they are just imagining things.
  3. C
    Inform the family members that sudden visual changes like this are an expected part of the normal aging process.
  4. D
    Apply soft wrist restraints immediately to prevent the client from accidentally injuring themselves while thrashing.

Answer

State calmly that while the client appears frightened, the nurse does not see any spiders.
When a client experiences a hallucination, the most appropriate initial nursing action is to acknowledge the client's feelings of fear or distress while gently presenting reality. This therapeutic technique validates the client's emotional state without reinforcing the false sensory perception.

Step-by-Step Solution

1
Identify the client's current sensory alteration.
The client is experiencing a visual hallucination, perceiving spiders on a blank wall.
Recognizing the alteration is required to select the appropriate therapeutic intervention.
2
Determine the priority nursing goal for a client experiencing hallucinations.
The goal is to maintain safety, validate the client's feelings, and gently present reality without reinforcing the false perception.
Directly challenging the hallucination causes defensive behavior, while playing along reinforces the delusion.
3
Select the intervention that best meets the therapeutic goal.
Acknowledging the fear and calmly stating that no spiders are visible validates the emotion while anchoring the client in reality.
This approach builds trust and uses therapeutic communication principles.

Key Concept

Therapeutic Communication during Sensory/Perceptual Alterations
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Topics

Sensory and Perceptual Alterations

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