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Soru

Zorluk: OrtaSensory and Perceptual Alterations

A 74-year-old client with profound vision loss is admitted to the medical unit for treatment of pneumonia. During the night shift, the client awakens in a darkened room, becomes acutely agitated, and claims that the shadows on the wall are intruders. The client attempts to climb over the bed rails. Which action should the practical nurse (PN) take first?

  1. Turn on a soft room light, approach the client calmly, introduce oneself, and provide verbal reorientation.Cevap
  2. B
    Ask the client, "Why do you believe there are intruders in here when the hospital doors are closed?"
  3. C
    Document the acute agitation as an expected symptom of normal aging and monitor the client from a distance.
  4. D
    Apply bilateral soft wrist restraints immediately to ensure physical safety and prevent a fall from the bed.

Cevap

The correct action is to turn on a soft room light, approach the client calmly, introduce oneself, and provide verbal reorientation.
The client is experiencing a visual illusion triggered by sensory deprivation (profound vision loss) combined with a dark, unfamiliar environment. The priority PN action is to decrease the sensory misperception by modifying the environment (turning on a soft light to eliminate shadows) and providing immediate reality orientation using a calm, non-threatening approach. This promotes client safety, reduces anxiety, and builds trust without resorting to restrictive measures.

Adım Adım Çözüm

1
Analyze the client's presentation and environmental factors.
The client has a sensory deficit (vision loss) and is in a dark, unfamiliar room, leading to a sensory illusion (misinterpreting shadows as intruders) and acute agitation.
Identifying the root cause of the perceptual alteration is necessary to select the most effective and least restrictive intervention.
2
Determine the immediate priority of care.
The priority is to maintain client safety and de-escalate the acute confusion without utilizing restrictive measures.
Client safety is always the highest priority during an acute perceptual crisis or delirium episode.
3
Select the most appropriate nursing intervention within the PN scope of practice.
Turning on a soft light removes the environmental trigger (shadows), while a calm introduction and verbal reorientation establish trust and ground the client in reality.
Environmental modification and therapeutic communication are the standard first-line treatments for sensory illusions and acute confusion.

Anahtar Kavram

Sensory and Perceptual Alterations
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Konular

Sensory and Perceptual Alterations

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