The most appropriate response for the nurse to make when a client with fluctuating levels of
consciousness, disturbed orientation, and perceptual alterations begs to have someone get the bugs
off her would be
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 away the bugs for you.".
d. "I don't see any bugs, but I know you are frightened so I will stay with you.".
D
When hallucinations are present, the nurse should acknowledge the client's feelings and state the
nurse's perception of reality, but not argue. Staying with the client increases feelings of security,
reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical
safety. Option A does not support the client emotionally. Option B makes the client responsible for
self-soothing. Option C supports the perceptual distortions.
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