A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response?
A) "No bugs are on your legs. You are having hallucinations."
B) "I will have someone stay here and brush off the bugs for you."
C) "Try to relax. The crawling sensation will go away sooner if you can relax."
D) "I don't see any bugs, but I can tell you are frightened. I will stay with you."

Question

Quizplus · Accepted Answer

When hallucinations are present, the nurse should acknowledge the patient's feelings and state the nurse's perception of reality, but not argue. Staying with the patient increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the patient's perception without offering help does not support the patient emotionally. Telling the patient to relax makes the patient responsible for self-soothing. Telling the patient that someone will brush the bugs away supports the perceptual distortions.

A Patient with Fluctuating Levels of Consciousness, Disturbed Orientation, and Perceptual