A client who sustained a right-sided cerebrovascular accident is receiving care on a subacute rehabilitation unit. The client has documented left homonymous hemianopsia. During the afternoon shift change, the unit environment is highly stimulating and loud. The client suddenly becomes agitated, points at an infusion pump, and states, "Who is that person standing in the shadows?" Which actions should the practical nurse take? (Select all that apply.)
- Dim the harsh overhead fluorescent lighting while keeping a small nightlight illuminated.Cevap
- BAttribute the sudden onset of the client's perceptual disturbance to expected age-related cognitive decline.
- Minimize ambient stimuli by partially closing the room door and silencing non-essential alarms.Cevap
- DApply soft extremity restraints to ensure the client does not pull on the infusion tubing while agitated.
- Approach the client cautiously from the right side while clearly stating the nurse's name.Cevap
- FReassure the client by stating, 'Don't worry, there is no one standing in the dark corner.'
Cevap
The correct actions are to dim the overhead lights while keeping a nightlight on, minimize ambient stimuli by closing the door and silencing alarms, and approach the client from their unaffected right side.
The client is experiencing an illusion fueled by sensory overload and a visual field deficit. The most effective interventions prioritize environmental modification and safety. Approaching the client from the unaffected (right) side prevents a startle response. Dimming harsh lighting while providing a soft nightlight eliminates the shadows that the client is misinterpreting as a person. Finally, decreasing ambient noise directly reduces the sensory overload that is escalating the client's agitation.
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Sensory Overload and Environmental Modification