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Zorluk: ZorSensory and Perceptual Alterations

An older adult client with bilateral hearing aids and a history of moderate dementia is hospitalized for pneumonia. At 0200, the client removes the hearing aids, becomes acutely agitated, and reports seeing "strangers crawling on the ceiling." The client is attempting to climb over the bed rails. Which action should the practical nurse (PN) take first?

  1. A
    Inform the client that the room is empty and instruct them to reinsert their hearing aids so they can hear instructions.
  2. B
    Apply bilateral soft wrist restraints to prevent a fall and turn off all lights to decrease sensory stimulation.
  3. Turn on a soft room light, approach the client directly in their line of sight, and state, "I am your nurse and you are safe here."Cevap
  4. D
    Document the agitation as expected sundowning behavior and close the door to keep the client confined to the room.

Cevap

Turn on a soft room light, approach the client directly in their line of sight, and state, "I am your nurse and you are safe here."
The correct action prioritizes the client's immediate physical safety and addresses the sensory-perceptual alteration. Turning on a soft light reduces shadows that can cause visual illusions. Because the client has removed their hearing aids, approaching directly in their line of sight is essential for communication. Stating who the nurse is and validating the client's safety provides therapeutic reorientation without arguing with the hallucination.

Adım Adım Çözüm

1
Analyze the client's current sensory and perceptual state.
The client is experiencing visual hallucinations or illusions compounded by sensory deprivation (dark room, removed hearing aids) and possible acute delirium from pneumonia.
Accurate assessment of the underlying cause of the agitation is required to determine the appropriate intervention.
2
Identify the immediate priority.
The client is attempting to climb over the bed rails, presenting an acute safety risk due to fear and disorientation.
Client safety is always the highest priority in a behavioral or sensory crisis.
3
Select the intervention that addresses safety, sensory deficits, and therapeutic communication.
Improving lighting, ensuring the client can see the nurse (due to hearing loss), and providing a calming, orienting statement directly mitigates the crisis.
These actions use least restrictive measures to restore reality and ensure safety.

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Sensory and Perceptual Alterations
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Sensory and Perceptual Alterations

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