A client suffering from visual hallucinations calls the nurse to her room and says, “You need to hurry up and kill all these bugs on the wall before they get on me.” Which response by the nurse is most appropriate?
“I don’t see them. Can you show me where they are?”
“I will call maintenance and have them come take care of this right away.”
“I know the bugs seem real to you, but I don’t see anything on the walls.”
Number 4 is correct.
Rationale: The nurse is presenting reality while acknowledging that the client’s perception is real to her. This response shows respect for the client’s feelings. Suggesting that the client take a nap diverts attention away from the topic and does not present a solution to the problem. This response may lead to agitation in the client. Options 2 and 3 acknowledge that the client’s misperception is real, and do not help reorient the client to reality. The nurse should never “play along” when clients are experiencing visual or auditory hallucinations.