A client who is agitated is gesturing at the television in the day room and talking to an empty chair. Which interventions should practical nurse (PN) implement? Select all that apply.
Explanation & Rationale
A. Instruct the client to stop scaring the other clients: Telling the client to stop the behavior may increase agitation and mistrust. Clients experiencing hallucinations are responding to stimuli they believe are real, so confrontation should be avoided. B. Offer support and reassure the client being in a safe place: Providing reassurance helps decrease anxiety and fear associated with hallucinations. Calm support conveys safety and establishes trust, which are essential in managing agitation. C. Instruct team members to ignore the client's hallucinations: Ignoring the client’s experience can worsen distress and feelings of isolation. Staff should respond therapeutically by acknowledging the client’s emotions without reinforcing the hallucination. D. Acknowledge that the client's perception is not real to others: This approach validates the client’s feelings while gently orienting them to reality. It helps maintain rapport and avoids reinforcing false perceptions, which supports reality testing. E. Restrict the client to his room and apply soft wrist restraints: Restraints and isolation are unnecessary unless the client poses an immediate danger to self or others. Such measures could escalate agitation and violate ethical standards of care. F. Use simple commands in a calm, soothing voice: Clear, calm communication helps the client process information more easily. It reduces overstimulation and conveys reassurance, aiding in the de-escalation of agitation.