A client is admitted to a private room under airborne precautions. On the third day of isolation, the client becomes extremely anxious and reports hearing whispering voices and seeing dark shadows moving across the walls. Arrange the practical nurse's interventions in the priority order of implementation. (Place the first action at the top and the last action at the bottom.)
- 1Enter the room, turn on the overhead lights, and clearly state one's name and role.
- 2Ask the client directly what the voices are saying to assess for potential harm.
- 3Acknowledge the client's distress while calmly presenting reality about the room.
- 4Open the window blinds and place a clock within the client's direct line of sight.
Cevap
The practical nurse should first provide a reality anchor, assess for command hallucinations to ensure safety, use therapeutic communication to validate distress, and finally modify the environment to prevent further episodes.
The nursing process and principles of prioritizing safety dictate the sequence of actions for a client experiencing perceptual alterations from sensory deprivation. First, the nurse must interrupt the episode by entering the room, increasing lighting, and identifying themselves to provide a strong reality anchor. Second, the nurse must assess for command hallucinations to ensure immediate safety. Third, the nurse uses therapeutic communication to validate the client's fear while presenting reality. Finally, long-term environmental modifications (such as providing natural light and a clock) are implemented to increase meaningful sensory input and prevent future episodes.
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Anahtar Kavram
Management of sensory deprivation and perceptual alterations