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Difficulty: MediumSensory and Perceptual Alterations

A client who recently experienced sudden and total vision loss following a traumatic injury is admitted to a surgical step-down unit. During the first night, the client becomes acutely agitated, attempts to remove the intravenous (IV) catheter, and shouts, "Who is in here? What are you doing to me?" Which action should the nurse take first?

  1. Speak to the client by name while entering the room, announce the nurse's presence, and gently touch the client's hand.Answer
  2. B
    Apply soft bilateral wrist restraints to secure the arms and prevent the immediate removal of the intravenous catheter.
  3. C
    Direct a patient care technician to sit at the bedside to provide continuous observation and prevent self-harm.
  4. D
    Ask the client, "Why are you pulling at your arm? You must leave the medical equipment alone so you can recover."

Answer

The priority action is to approach the client calmly, announce one's presence by speaking the client's name, and use a gentle touch.
The correct action directly addresses the client's acute sensory loss and resulting disorientation. By speaking the client's name clearly upon entering, stating their presence, and using gentle tactile stimulation, the nurse replaces the missing visual input with meaningful auditory and tactile stimuli. This helps reorient the client, reduces fear, and de-escalates the agitation without using restrictive measures.

Step-by-Step Solution

1
Analyze the client's behavior and clinical history.
The client has sudden, complete vision loss and is exhibiting signs of acute fear, disorientation, and sensory deprivation in an unfamiliar environment.
Understanding that the agitation stems from a lack of visual input and fear of the unknown guides the choice of intervention.
2
Evaluate the available interventions based on the nursing process and safety principles.
Restraints are a last resort. Delegating to a technician bypasses RN assessment. Asking 'why' is non-therapeutic. Providing orienting stimuli is safe and addresses the root cause.
The least restrictive, most direct therapeutic intervention must be prioritized for a client experiencing sensory alterations.
3
Select the action that provides appropriate sensory input.
Using auditory (speaking name, announcing presence) and tactile (gentle touch) stimuli effectively compensates for the lack of visual stimuli.
This establishes trust, grounds the client in reality, and mitigates the panic caused by sensory deprivation.

Key Concept

Nursing management of acute sensory deprivation and perceptual alterations requires providing compensatory, orienting stimuli (auditory and tactile) to maintain safety and reduce severe anxiety.
Estimated Time:1m 15s
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Topics

Sensory and Perceptual Alterations

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