Psychiatric Assessment and Fundamentals Q 40
Nurse Tina is caring for a client with delirium and states that “look at the spiders on the wall”. What should the nurse respond to the client?
A. “You’re having hallucination, there are no spiders in this room at all”
B. “I can see the spiders on the wall, but they are not going to hurt you”
C. “Would you like me to kill the spiders”
D. “I know you are frightened, but I do not see spiders on the wall”
Correct Answer: D. “I know you are frightened, but I do not see spiders on the wall”
When hallucination is present, the nurse should reinforce reality with the client. Interrupt periods of unreality and reorient; client safety is jeopardized during periods of disorientation; correcting misinterpretations of reality enhances client’s feelings of self-worth and personal dignity.
Option A: Assess the client’s level of anxiety and behaviors that indicate the anxiety is increasing; recognizing these behaviors, the nurse may be able to intervene before violence occurs. Maintain a low level of stimuli in the client’s environment (low lighting, few people, simple decor, low noise level) because anxiety increases in a highly stimulating environment.
Option B: Maintain a calm manner with the client; attempt to prevent frightening the client unnecessarily; Provide continual reassurance and support. Have sufficient staff available to execute a physical confrontation, if necessary; assistance may be required from others to provide for the physical safety of the client or primary nurse or both.
Option C: Remove all potentially dangerous objects from the client’s environment; in a disoriented, confused state, clients may use objects to harm self or others. Sit with the client and provide one-to-one observation if assessed to be actively suicidal; client safety is a nursing priority, and one-to-one observation may be necessary to prevent a suicidal attempt.