During a home care visit, the practical nurse (PN) observes a bedbound client who spends most of the day in a dimly lit room. The client suddenly becomes agitated, attempts to pull out their indwelling urinary catheter, and yells, "Get these snakes off my legs!" The PN recognizes a perceptual alteration likely caused by sensory deprivation. In which order should the PN perform the following interventions? Arrange the actions from first to last.
- 1Stay with the client and gently guide their hands away from the urinary catheter.
- 2Acknowledge the client's fear while stating that there are no snakes present.
- 3Turn on the room lights and open the curtains to increase environmental stimuli.
- 4Provide the client with a rolled washcloth to hold and manipulate in their hands.
- 5Notify the supervising registered nurse (RN) regarding the client's acute confusion.
Cevap
The correct sequence prioritizes immediate physical safety, followed by therapeutic communication, environmental modification, sensory distraction, and finally, collaboration with the healthcare team.
The correct sequence of actions follows the nursing priorities of safety, therapeutic communication, environmental intervention, and collaboration. The highest priority is preventing physical injury by safely guiding the client's hands away from the catheter. Next, presenting reality helps ground the frightened client. Then, the underlying sensory deprivation is addressed by increasing lighting, which removes shadows that can cause illusions. Offering a tactile distraction prevents recurrence of the unsafe behavior. Finally, the RN is notified of the acute change in the client's condition for further evaluation.
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Anahtar Kavram
Prioritization of nursing care for a client experiencing perceptual alterations requires addressing immediate physical safety first, followed by reorientation, environmental modifications, and reporting.