A client with bilateral cataracts and a history of mild cognitive impairment is 48 hours post-operative following a right hip arthroplasty. At 0300, the client becomes extremely agitated, attempting to climb out of bed and shouting, "The spiders are crawling out of that blinking box!" while pointing at the intravenous infusion pump. The room is dark except for the pump's lights, and hallway alarms are echoing loudly. Which action should the licensed practical nurse (PN) take first?
- Turn on a soft bedside light, state the nurse's name, and identify the blinking object as the intravenous pump.Answer
- BInform the client that there are no spiders in the room and ask why they are feeling so frightened.
- CApply bilateral soft wrist restraints to prevent the client from injuring the operative hip during the agitation.
- DAssign the unlicensed assistive personnel to remain at the bedside while the nurse reviews the client's medical record.
Answer
The correct action is to turn on a soft bedside light, state the nurse's name, and identify the blinking object as the intravenous pump.
The client is experiencing an illusion, which is a misinterpretation of a real external stimulus (the blinking IV pump light). This misperception is exacerbated by the client's underlying bilateral cataracts (poor visual acuity) and the dark, noisy environment. Turning on a soft light improves the client's ability to see clearly and removes the shadows causing the visual distortion, while calmly introducing oneself and identifying the object provides immediate reality orientation and promotes physical safety.
Step-by-Step Solution
Key Concept
Management of sensory and perceptual alterations requires environmental modification and reality orientation as a first-line intervention, prioritizing safety without immediately resorting to physical or chemical restraints.