An older resident of a nursing home reports to the nurse that during the night someone entered her room and stood by the window watching her. She expresses fear of going to sleep. What action is most appropriate for the nurse to take initially?
a. Reassure her that there was no one in her room and that she must have been dreaming.
b. Request a psychiatric consult to evaluate her for cognitive problems.
c. Assess the environment in her room to see if there is anything that could be confusing her.
d. Suggest to her that she request sleeping medication every night.
ANS: C
She is likely experiencing delusions, which are frightening for her. The first step is assess-ment of the truth of the delusion. The nurse assesses the environment to see if there is any-thing that could have been misinterpreted by the resident. Concluding that someone is delu-sional is never safe unless the claim has been thoroughly investigated. Consulting a psychiatrist is not the first option; if symptoms interfere with function, than a psychiatric evaluation and medication management might be indicated. Medicating for sleep will not help with the delusions.
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