Page 2285 - Saunders Comprehensive Review For NCLEX-RN

▪ Encourage the client to express feelings and focus on feelings that the delusions
generate.
▪ If the client obsesses on the delusion, set firm limits on the amount of time spent
talking about the delusion.
▪ Do not argue with the client or try to convince the client that the delusions are
false.
▪ Validate if part of the delusion is real.

Box 65-12
Hallucinations

Description

Sense perception (occurs with 1 of the 5 senses) for which no external stimuli
exist; can have an organic or functional cause

Types

Auditory: Hearing voices when none are present
Gustatory: Experiencing taste in the absence of stimuli
Olfactory: Smelling smells that do not exist
Tactile: Feeling touch sensations in the absence of stimuli
Visual: Seeing things that are not there

Interventions

▪ Ask the client directly about the hallucination.
▪ Avoid reacting to the hallucination as if it were real.
▪ Decrease stimuli or move the client to another area.
▪ Do not negate the client’s experience.
▪ Focus on reality-based topics.
▪ Attempt to engage the client’s attention through a concrete activity.

▪ Respond verbally to anything real that the client talks about.
▪ Avoid touching the client.
▪ Monitor for signs of increasing anxiety or agitation, which may indicate that
hallucinations are increasing.

Box 65-13

Language and Communication Disturbances

2285