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Question

Difficulty: EasySensory and Perceptual Alterations

A practical nurse (PN) is caring for an older adult client in a long-term care facility. The client suddenly becomes agitated and states, "The voices are telling me to hide under the bed." Which of the following is the best initial response by the nurse?

  1. I do not hear any voices, but I can see that you are frightened.Answer
  2. B
    Why do you think the voices are telling you to do that?
  3. C
    These voices are just a normal part of getting older and having dementia.
  4. D
    You need to wear soft wrist restraints so you do not hurt yourself.

Answer

The nurse should present reality by stating they do not hear the voices, while simultaneously validating the client's feelings of fear.
The correct response effectively acknowledges the client's underlying emotion (fear) and grounds them by calmly presenting reality. This is the standard of care for a client experiencing an active hallucination.

Step-by-Step Solution

1
Analyze the client's statement and behavior.
The client is experiencing an active auditory hallucination and is displaying visible agitation and fear.
Identifying the nature of the perceptual alteration helps determine the safest and most therapeutic response.
2
Select the appropriate therapeutic communication technique.
The nurse chooses to present reality and validate feelings without arguing.
Arguing with the client or asking 'why' questions increases agitation, whereas presenting reality while validating fear builds trust and promotes safety.

Key Concept

Therapeutic communication for sensory and perceptual alterations
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Topics

Sensory and Perceptual Alterations

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