Interventions with Client will be able to defi 3. An attitude of acceptance will encourage the client to share 2. Avoid touching the client before warning him or her that you 1. Observe client for signs of hallucinations (listening pose, [Inappropriate responses][Rapid mood swings][Exaggerated emotional responses][Visual and auditory distortions][Talking and laughing to self ][Listening pose (tilting head to one side as if listening)][Stops talking in middle of sentence to listen]Goals/ObjectivesShort-term GoalClient will be able to recognize and verbalize when he or she is interpreting the environment inaccurately.Long-term Goal^156 occurrence of sensory misperceptions.hallucinations.laughing or talking to self, stopping in midsentence). the content of the hallucination with you. intervention may prevent aggressive responses to command are about to do so.and respond in an aggressive manner.^ ●^ ALTERATIONS IN PSYCHOSOCIAL ADAPTATIONSelected Rationales Client may perceive touch as threatening ne and test reality, eliminating the This is important Early
2506_Ch07_145-160.indd 0156 2506 Ch 07 145 - 160 .ind6. Try to distract the client away from the misperception. 5. Try to connect the times of the misperceptions to times of^ 4. Do not reinforce the hallucination. Use words such as “the d CLINICAL PEARL voices speaking.” The nurse must be honest with the client so that he or she may realize that the hallucinations are not real. share the perception. 0 If client can learn to interrupt the escalating anxiety, real-from command hallucinations.ity orientation may be maintained.Words like “they” validate that the voices are real.in order to prevent possible injury to the client or others Involvement in interpersonal activities and explana-tion of the actual situation may bring the client back toreality.increased anxiet y. Help client to understand this connection. voices” instead of “they” when referring to the hallucination. 15 Say, “Even though I realize that the voices are real to you, I do not hear any 6 Let the client who is “hearing voices” know that you do not^ 10/1/10 9:34:51 AM 10 / 1 / 10 9 : 34 : 51 AM