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Difficulty: MediumSensory and Perceptual Alterations

While receiving evening care, a client with early-stage Alzheimer's disease points to a shadow cast by an intravenous fluid pole and frantically states, "There is a tall man standing in the corner waiting to hurt me!" Which action should the nurse take first?

  1. Turn on the room lights and calmly state that the shape is just a shadow from the equipment.Answer
  2. B
    Ask the client to describe the man's appearance and what he is doing in the room.
  3. C
    Explain to the client that older adults frequently experience vision changes that cause them to see things.
  4. D
    Instruct the unlicensed assistive personnel to sit with the client while the nurse notifies the healthcare provider.

Answer

Turn on the room lights and calmly state that the shape is just a shadow from the equipment.
The client is experiencing an illusion, which is a misinterpretation of a real environmental stimulus. The most effective first action is to alter the sensory environment (turning on the lights) to remove the source of the shadow and calmly orient the client to reality. This provides immediate relief and establishes safety.

Step-by-Step Solution

1
Analyze the client's behavior and statement.
The client is misinterpreting a real external stimulus (the shadow from the IV pole) as a threatening person.
Identifying that the client is experiencing an illusion rather than a hallucination or delusion directs the appropriate intervention.
2
Determine the priority nursing intervention for visual illusions.
The immediate priority is to modify the environment to remove the stimulus and provide reality orientation.
Illusions are often triggered by poor lighting or unfamiliar environments. Correcting the sensory environment immediately alleviates the distress.
3
Evaluate the provided options against therapeutic communication and safety standards.
Altering the lighting and calmly explaining the source of the shadow is the only therapeutic and safe initial action.
Other actions inappropriately delegate care, minimize the client's feelings, or reinforce the misperception.

Key Concept

Nursing Management of Visual Illusions
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Topics

Sensory and Perceptual Alterations

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