A patient with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get the bugs off me." What is the nurse's best response?
a. "There are no bugs on your legs. Your imagination is playing tricks on you."
b. "Try to relax. The crawling sensation will go away sooner if you can relax."
c. "Don't worry, I will have someone stay here and brush off the bugs for you."
d. "I don't see any bugs, but I know you are frightened so I will stay with you."
ANS: D
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 emotionally support the patient. 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.
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