An older adult client with moderate hearing loss is receiving intravenous fluids for dehydration. During the night shift, the client suddenly becomes extremely distressed, points at the infusion pump in the dimly lit room, and yells, "Who is that person standing in the corner? Get him out of here!" Which action should the practical nurse take first?
- Turn on the bedside light, state the client's name, and explain that the object is an infusion pumpCevap
- BTell the client there is no one else in the room and firmly instruct them to go back to sleep
- CDocument the behavioral change in the medical record as an expected finding for an older adult at night
- DApply bilateral soft wrist restraints immediately to prevent the client from dislodging the intravenous line
Cevap
Turn on the bedside light, state the client's name, and explain that the object is an infusion pump.
The client is experiencing an illusion, which is a false perception of a real external stimulus. In a dimly lit room, medical equipment can easily be misinterpreted, especially by older adults with sensory deficits like hearing loss, who rely more heavily on visual cues. The first priority is to manipulate the environment to correct the sensory alteration. Turning on the light provides adequate visual input, while addressing the client by name and explaining the object offers therapeutic reality orientation.
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Anahtar Kavram
Interventions for Sensory Alterations and Illusions