A nurse is caring for a 75-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.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for managing wandering behavior in a patient with Alzheimer's disease. The core principle is non-pharmacological, least-restrictive safety management. Wandering is a common behavioral symptom of dementia, often driven by confusion, anxiety, or unmet needs. The nursing priority is to protect the patient from harm (e.g., falls, elopement) while preserving their dignity and autonomy as much as possible. The Key Point! is to choose interventions that monitor and redirect, not restrict or sedate unnecessarily.
Answer Rationale: Option ③, "Install a bed alarm and provide close supervision with frequent rounds," is correct because it embodies the principles of patient-centered care and safety without undue restraint. A bed alarm is a safety monitoring device that alerts staff when the patient attempts to get up, allowing for timely intervention. Combined with frequent rounding, this approach provides continuous observation and the opportunity for redirection or reassurance. It addresses the safety risk while minimizing the physical and psychological risks associated with restraints or sedatives.
Distractor Analysis:
Watch out for confusion! Option ①, applying wrist restraints, is a restrictive intervention that should be an absolute last resort. Restraints can increase agitation, cause injury (skin breakdown, nerve damage), and lead to serious complications like deep vein thrombosis (DVT) or aspiration pneumonia. Their use is heavily regulated and requires a specific physician's order, frequent monitoring, and documentation. It violates the principle of least restriction.
Option ②, administering a sedative PRN (as needed), poses significant risks for older adults with dementia. Sedatives can increase the risk of falls, confusion (paradoxical agitation), and other adverse effects. The Beers Criteria, a list of potentially inappropriate medications for older adults, cautions against the use of many sedatives in dementia due to these risks. Pharmacological interventions should not be the first-line for behavioral symptoms.
Option ④, moving the client closer to the nurses' station, is a supportive environmental modification and can be part of a comprehensive plan. However, by itself, it is not the priority immediate safety intervention for active nighttime wandering. Proximity does not guarantee constant observation or prevent the patient from leaving their room. This is a good secondary intervention but does not provide the direct, active monitoring that the bed alarm and frequent rounds offer.
Related Concepts: This scenario connects to broader concepts in gerontological and psychiatric nursing: managing sundowning (increased confusion and agitation in the late afternoon/evening), creating a therapeutic milieu, using validation therapy instead of confrontation, and understanding the ethical and legal implications of restraint use. The nursing process guides us to first assess for triggers (pain, full bladder, noise) before intervening.
Concept Summary
Concept
Description
Nursing Implication
Wandering in Dementia
Aimless or purposeful locomotion, often a manifestation of anxiety, boredom, or unmet needs.
Assess for triggers, ensure safety, use monitoring devices, provide structured activities.
Least Restrictive Intervention
A legal and ethical principle mandating the use of the least confining method to ensure safety.
Try environmental (alarms), social (supervision), before physical (restraints) or chemical (sedatives) methods.
Sundowning
Worsening of confusion and behavioral symptoms in the late day/evening.
Increased fall risk, cognitive impairment, paradoxical reactions, side effects.
Only for severe, dangerous agitation per protocol; not for simple wandering.
Anatomy, Physiology & Pharmacology Points
- Neurological: Alzheimer's disease involves progressive degeneration of brain cells, particularly in areas like the hippocampus (memory) and frontal lobe (judgment, behavior). Wandering may be linked to damage in the parietal lobe (spatial orientation).
- Pharmacology: Medications like benzodiazepines (e.g., lorazepam) and typical antipsychotics (e.g., haloperidol) carry a "black box warning" for increased mortality in elderly patients with dementia. They should be used at the lowest dose for the shortest duration if absolutely necessary.
Memory Tips
- Acronym: S.A.F.E. for managing dementia behaviors: Search for triggers, Assess needs (pain, toileting), Facilitate a safe Environment, Engage and redirect.
- Mnemonic: "Alarms Before Arms." Use monitoring Alarms before resorting to physical restraint of the Arms.
- Think: Least Restrictive = First Choice. The NCLEX always favors interventions that maximize patient freedom and safety.
High-Frequency NCLEX Topics
Safety and infection control are the largest content areas on the NCLEX. Questions on restraint use, fall prevention, and caring for clients with cognitive impairment are extremely common. You must know the hierarchy of interventions, the requirements for restraint use (order, time limits, monitoring), and the specific risks for the elderly population.
Watch Out for Question Variations!
- Instead of "priority intervention," the question could ask: "The nurse is developing a plan of care. Which goal is most appropriate?" (Answer: Client will remain free from injury.)
- It could shift to a medication question: "The healthcare provider prescribes lorazepam 0.5 mg PO for nighttime agitation. What is the nurse's best action?" (Answer: Contact the provider to discuss non-pharmacological options first due to fall risk in elderly dementia.)
- It could test delegation: "Which task can the nurse delegate to an unlicensed assistive personnel (UAP) regarding this client?" (Answer: "Please check on Mr. Smith every 30 minutes and report if he is out of bed." The nurse retains responsibility for assessment and initiating the alarm system.)
Nursing Clinical Practice GuideClinical Scenario: You are the night shift nurse on a medical-surgical unit. Mr. Johnson, a 75-year-old with moderate Alzheimer's, is a new admission. His family reports he "paces at home at night." At 2 AM, the nurse call light is not used, but you hear soft footsteps and see his shadow moving past his doorway. You find him in the hallway, dressed in his street clothes, trying to find the "bus stop to go home."
Nursing Intervention Strategy:
1Immediate Assessment & ApproachApproach calmly. Use a low, reassuring tone. "Mr. Johnson, it's Nurse Alex. It's nighttime now. Let's walk back to your room together." Use validation therapy—acknowledge his feeling ("It must be confusing to be in a new place") rather than correcting his reality ("There's no bus stop here").
2Safety ImplementationEscort him back to his room. Ensure the bed alarm sensor pad is properly placed under the bottom sheet and connected. Explain its purpose simply: "This pad lets me know if you need help getting up." Document the wandering event and your intervention.
3Ongoing Monitoring & Care PlanInform the team during handoff. Increase rounding schedule to every 30 minutes. Collaborate with the day shift to assess for triggers—could he have urinary tract infection (UTI) causing confusion? Is he in pain? Ensure he has adequate daytime physical activity to promote nighttime sleep.
Patient Safety and Precautions:
1Restraint PrecautionsPhysical restraints are a sentinel event risk. If, after all alternatives, a restraint is deemed necessary, you must have a physician's order specific to duration and type, assess skin and circulation every 15-30 minutes, release restraints every 2 hours for range of motion, and document meticulously.
2Medication Precautions- Before administering any PRN sedative, perform a thorough fall risk assessment.
- Monitor for signs of orthostatic hypotension (dizziness upon standing).
- Be aware of the increased sensitivity of the aging brain to CNS depressants.
Nursing Procedure & Medication FlowProcedure: Applying and Monitoring a Bed/Chair Alarm
1. Assess the device for proper function.
2. Place the pressure-sensitive pad or clip-on sensor according to manufacturer guidelines (often under the torso area of bedsheet or on clothing).
3. Set the alarm to a volume audible at the nurses' station. Test it.
4. Educate the patient and family (simply) about its purpose as a safety reminder, not a punishment.5. Critical: Respond to every alarm promptly to assess the patient's need.
6. Document the use of the device in the care plan and flow sheet.Medication Flow (If Sedative is Prescribed & Necessary)
1AssessmentCheck vital signs, especially blood pressure. Perform a fall risk score (e.g., Morse Fall Scale).
2AdministrationAdminister the lowest effective dose. For example, liquid formulations may allow for more precise dosing.
3MonitoringAfter administration, ensure side rails are up (if appropriate), the bed is in the lowest position, and the call light is within reach. Reassess in 30-60 minutes for effectiveness and side effects.
4EvaluationDocument the patient's response: Was agitation reduced? Did the patient fall asleep? Were there any adverse effects?
A Word from Your Senior Nurse
Caring for patients with dementia requires immense patience and a shift in perspective. Your goal isn't to "fix" their confusion but to enter their world and keep them safe there. That bed alarm isn't just a piece of technology; it's your promise to that patient that you'll be there if they try to get up. On the NCLEX and in real life, the answer that promotes safety with the most respect for the person is almost always the right one. Remember, we care for a person with a disease, not a diseased person. That mindset guides every good nursing intervention.