The nurse assistant is caring for a client with delirium when the client says, “Look at the spiders on the wall.”What should the nurse assistant say to the client?
  1. “You’re having hallucinations. There are no spiders in this room at all.”
  2. “I can see the spiders on the wall, but they are not going to hurt you.”
  3. “Would you like me to kill the spiders?”
  4. “I know you are frightened, but I do not see spiders on the wall.”
Explanation
Answer: D -The nurse assistant should say, “I know you are frightened, but I do not see spiders on the wall.” Clients with delirium sometimes experience hallucinations. It is appropriate to acknowledge the feelings of the client and to present reality initially. Do not argue with the person. Reassure him/her; tell the client that you will provide protection from harm.
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