Question

An elderly client in an extended care facility hollers from her bed “Nurse, help me. They are throwing dishes at me.” Which is the best response on the part of the nurse? A. “What kind of dishes is someone throwing at you?” B. “Have a drink of water and by then it will be over.” C. “I don’t see anyone throwing dishes but it must be scary for you; you are safe here.” D. “Why do you think anyone would want to throw dishes at you? You have never hurt anyone have you?

Short answer

The best response is C, because it acknowledges the client's distress, does not affirm the delusion, and provides reassurance of safety.

Step-by-step solution

Understand the Situation

First, understand the situation described. The client is likely experiencing a hallucination or delusion since there is no evidence of actual danger.

Acknowledge the Feelings

It is important for the nurse to acknowledge the client's feelings without affirming the delusion. The nurse should provide reassurance and convey safety.

Choose the Best Response

Evaluate each response option. Option A could potentially affirm the delusion. Option B might be dismissive of the client's feelings. Option D could lead to further agitation. Option C acknowledges the client's distress without affirming the delusion and offers reassurance.

Key concepts

Nursing Care for Hallucinations

When caring for patients experiencing hallucinations, the primary goal of nursing care is to ensure their safety and comfort. An understanding and empathetic approach is crucial, as hallucinations can be extremely frightening and disorienting for the individual. Nurses must assess the situation quickly to make sure there are no real threats to the patient's well-being.

Interventions include speaking calmly and reassuringly to the patient to affirm their security within the care setting. It's vital to acknowledge the patient's experience without validating the hallucination, as this can reinforce the false perception. For instance, telling a patient who believes they're in danger that they are safe and that you are there to protect them can help reduce anxiety.

• Remain nonjudgmental and show empathy towards their experiences.
• Assess the level of distress and provide a calm, safe environment.
• Use clear, simple communication to avoid adding confusion.
• Redirect the conversation towards reality-based topics gradually if possible.

Nurse-Client Communication

Effective communication is pivotal to good nursing practice, especially when dealing with patients suffering from hallucinations or delusions. It encompasses the ability of the nurse to listen actively, respond appropriately, and convey genuine concern for the client's feelings and perceptions.

The nurse must avoid arguing or challenging the hallucination directly. Instead, using therapeutic communication techniques can help validate the patient's feelings without reinforcing the hallucination. For example, a response that demonstrates understanding and offers reassurance can ease the patient's distress and helps build a trusting relationship. Offering distractions or engaging in reality-based conversations are techniques that can shift focus away from the hallucinations.

• Use verbal and nonverbal cues to convey empathy and understanding.
• Focus on the emotions the patient is expressing rather than the content of the hallucination.
• Maintain a calm, non-threatening demeanor to avoid escalating the situation.

Psychosocial Integrity

Psychosocial integrity in nursing involves addressing the psychological, sociocultural, developmental, and spiritual needs of the patient. In the context of hallucinations, addressing psychosocial integrity means understanding the impact of hallucinations on a patient's emotional and mental state and providing holistic care that respects their feelings and health beliefs.

It is essential to create a supportive care plan that includes elements like counseling, stress reduction techniques, and possibly collaboration with other healthcare professionals like psychiatrists or social workers. A primary objective is to help the patient maintain a sense of reality while alleviating fear and distress.

• Offer support groups or counseling services for ongoing psychosocial support.
• Engage in activities that promote relaxation and stress reduction.
• When appropriate, involve family or community support resources.

By addressing the psychosocial needs, nurses play a critical role in promoting mental health and psychological well-being.