A nurse is caring for a 70-year-old client with moderate Alzheimer's disease who has been wandering at night and attempting to leave the unit. Which nursing intervention should be the priority to ensure client safety?
1Apply bilateral wrist restraints during nighttime hours
2Administer a sedative medication as needed for agitation
3Install a bed alarm and provide close supervision with frequent rounds✓ 정답
4Move the client to a room closer to the nurses' station
해설
Installing a bed alarm and providing close supervision is the priority safety intervention for wandering in dementia, as it ensures monitoring with minimal restriction. Other options involve restraints or sedatives that increase risks.
Clinical Judgment
The core of this problem is balancing safety and the principle of least restraint. The patient wanders at night and shows confusion and agitation, posing a high risk of falls, elopement, and harm to other patients. The priority intervention should be a method that reduces these risks without compromising the patient's dignity and avoids unnecessary physical/chemical restraints. Install a bed alarm and provide close supervision allows for real-time monitoring of the patient's movements and enables an immediate response when a dangerous situation occurs. This is a primary preventive approach that provides an effective safety net while minimizing restraint.
Memory Tip:
Remember Least Restrictive, Most Safe (LRMS). Securing maximum safety with minimum restraint is the core principle of dementia patient care. A Bed Alarm is a representative tool that implements this principle.
KR vs US:
In Korea, there may be a tendency to rely more on mobilizing family members or adjusting the physical environment, but in the US NGN/CJMM, respect for patient autonomy and evidence-based interventions are emphasized. The systematic use of technological aids like bed alarms and protocolized supervision systems such as 'frequent rounding' are established as standard practice.
Clinical Practice Guide
When managing wandering behavior in dementia patients, consider the following steps: 1) Assess the cause (pain, toileting needs, anxiety, environmental stimuli), 2) Implement least restrictive interventions (alarms, providing safe walking spaces), 3) Use medication only as a last resort, 4) Provide family education and environmental modifications.
Caution:
In SATA questions, "Apply restraints" is almost always the wrong answer. In U.S. nursing, restraint use is extremely limited and can only be used for very short periods under a physician's order and specific conditions. "Sedative PRN" should also be approached cautiously due to the risk of falls and cognitive decline.
Alzheimer's Disease — The most common degenerative brain disease, it is a neurocognitive disorder that causes impairments in memory, thinking, and behavior.
Wandering — Aimless or disoriented walking behavior commonly observed in dementia patients, which poses a significant safety risk.
Least Restrictive Intervention — This is an ethical and legal principle that first attempts the least restrictive method possible, ensuring patient safety while maximizing their freedom and dignity.
Bed Alarm / Exit Alarm — A sensing device that sends an alert to the nurse when the patient tries to get out of bed or leave a designated area, used for preventive safety management.
Chemical Restraint — This refers to sedatives or psychotropic medications administered primarily to control a patient's behavior. They are used very restrictively under the principle of minimal restraint.