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Zorluk: ZorSensory and Perceptual Alterations

An older adult client is on strict contact isolation in a dimly lit private room for treatment of a multidrug-resistant organism. During evening rounds, the client becomes intensely agitated, pointing toward a coat rack in the corner and yelling, "Make that person leave, they are waiting to attack me!" Which action should the practical nurse (PN) take first?

  1. Acknowledge the client's fear, present reality without arguing, and increase the lighting in the room.Cevap
  2. B
    Assure the client there is nothing to worry about and logically explain how the coat rack is casting a shadow.
  3. C
    Record the visual disturbance in the chart as an expected behavioral change related to advanced age.
  4. D
    Prepare and administer the client's prescribed as-needed intravenous haloperidol to manage the acute agitation.

Cevap

The priority action is to validate the client's feelings of fear, gently state what is actually there, and improve the environmental lighting to eliminate the shadow causing the illusion.
The correct action directly addresses both the emotional and environmental components of an illusion. Acknowledging fear builds therapeutic trust. Presenting reality without arguing provides orientation, and increasing the lighting removes the shadow that is triggering the sensory misperception.

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1
Analyze the client's clinical presentation.
The client is experiencing an illusion (misinterpreting a real environmental stimulus—the coat rack) exacerbated by the dimly lit environment and sensory deprivation from isolation.
Accurate identification of the perceptual alteration dictates the specific nursing intervention.
2
Evaluate the proposed interventions against safety protocols and the PN scope of practice.
Intravenous push medications are outside the PN scope, and documenting the event as 'normal aging' ignores the acute nature of the crisis. Using logic or false reassurance is non-therapeutic.
The nurse must select an intervention that is safe, therapeutic, and legally permissible.
3
Determine the priority therapeutic response.
The nurse must address the client's immediate emotional distress (fear) and correct the environmental deficit (dim lighting) without arguing.
Validating emotions builds trust, while altering the environment removes the trigger for the illusion.

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Sensory and Perceptual Alterations
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Sensory and Perceptual Alterations

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