An 82-year-old client with moderate dementia is admitted to the medical unit. The client becomes increasingly agitated during the evening hours, attempting to leave the unit and calling out for deceased family members. Which nursing intervention should the nurse implement first to ensure the client's safety?
1Administer prescribed PRN lorazepam to reduce anxiety and agitation
2Apply soft wrist restraints to prevent the client from leaving the bed
3Redirect the client's attention using validation therapy and familiar objects✓ 정답
4Place the client in a room closer to the nurses' station for constant observation
해설
Validation therapy and redirection with familiar objects address emotional needs and maintain safety in sundown syndrome, avoiding restraints or sedation as first-line interventions.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with dementia experiencing Sundowning (increased agitation, confusion, and behavioral disturbances in the late afternoon or evening). The core principle is the Least Restrictive/Invasive Intervention. In geriatric and psychiatric nursing, the goal is to manage behavioral symptoms using non-pharmacological, person-centered approaches first to preserve dignity, autonomy, and safety.
Answer Rationale: Key Point! The first intervention should be the least restrictive method that addresses the underlying cause of the agitation. For sundowning in dementia, agitation often stems from unmet needs (fear, disorientation, boredom) or environmental triggers. Redirecting with validation therapy and familiar objects (Option 3) is the correct first step. Validation therapy acknowledges the patient's feelings (e.g., "It sounds like you miss your family") rather than correcting them, which can reduce conflict. Redirection to a calming, familiar activity (like looking at a photo album) can de-escalate the situation safely without coercion.
Distractor Analysis:
Option 1 (Administer PRN lorazepam): While medication may sometimes be necessary, it is not the first intervention. Antipsychotics and benzodiazepines like lorazepam increase fall risk, can cause paradoxical agitation, and have significant side effects in older adults. They are considered only after non-pharmacological methods fail and with careful risk-benefit assessment.
Option 2 (Apply soft wrist restraints): Watch out for confusion! Physical restraints are a last resort due to ethical and safety concerns. They can increase agitation, cause injury, and lead to complications like pressure ulcers or loss of dignity. Their use is heavily regulated and requires a specific order, often only when the patient poses an imminent danger to self or others.
Option 4 (Place client near nurses' station): This is a good supportive safety measure and should be part of the care plan. However, it is an environmental modification, not the first active nursing intervention to address the immediate agitated behavior. Constant observation is resource-intensive and does not, by itself, calm the patient or address the emotional trigger.
Related Concepts: This scenario integrates principles of Gerontological Nursing, Psychiatric-Mental Health Nursing, and Patient Safety. Understanding the progression of dementia, communication techniques (validation vs. reality orientation), and the hierarchy of behavioral interventions is crucial.
Concept Summary
Concept
Description
Nursing Implication
Sundowning
Increased confusion & agitation in dementia patients during evening/night.
Pathophysiology of Sundowning: Not fully understood but linked to degeneration of the brain's suprachiasmatic nucleus (the body's clock), leading to circadian rhythm disruption. Fatigue, low lighting, and shadows can worsen perceptual errors.
Pharmacology Caution: Key Point! Older adults have altered pharmacokinetics (slower metabolism, excretion). Benzodiazepines (lorazepam) have a Black Box Warning for increased risk of falls, cognitive impairment, and dependence in the elderly. Antipsychotics carry an FDA warning for increased mortality in elderly patients with dementia-related psychosis.
Memory Tips
Acronym: V.R.P.S. for intervention hierarchy: Validation & Redirection (first) -> Pharmacological (with caution) -> Seclusion/Restraint (last, with S for Safety/Supervision).
Think "Talk, Don't Lock": Always attempt communication and therapeutic interaction before considering restrictive measures.
High-Frequency NCLEX Topics
The NCLEX heavily tests safety and ethical care. Questions on dementia/agitation often test:
Priority action using the least restrictive principle.
Differentiating between appropriate redirection techniques (validation) and inappropriate ones (confrontation).
Knowing when a restraint requires a physician's order and the associated nursing responsibilities (frequent checks, release, documentation).
Watch Out for Question Variations!
Shift from "First Intervention" to "Evaluate Effectiveness": "The nurse uses validation therapy. Which client statement indicates the intervention is effective?" (Correct answer: Client's agitation decreases and they engage in a calming activity.)
Shift to "Priority Diagnosis": "Based on the client's behavior, which nursing diagnosis is priority?" (Correct answer: Risk for Injury related to confusion and agitation.)
Shift to "Medication Education": "The physician prescribes lorazepam PRN for agitation. Which statement by the nurse during education is correct?" (Correct answer: "This medication can make you dizzy, so call for help before getting up.")
Nursing Clinical Practice GuideClinical Scenario: You are the night shift nurse on a medical-surgical unit. Mr. Johnson, an 82-year-old with moderate Alzheimer's disease, becomes increasingly restless around 8 PM. He is trying to open the unit's exit door, saying he needs to go home to see his wife (who passed away years ago). He is mildly confused during the day but is now visibly anxious and pulling at his IV line.
Nursing Intervention Strategy:
Immediate Assessment & Safety: Approach calmly. Assess for immediate dangers (untethered IV, obstacles). Use a calm, low-pitched voice. Say, "Mr. Johnson, I can see you're upset. My name is Sarah, I'm your nurse tonight. Let's sit down over here where it's comfortable."
Therapeutic Communication & Redirection: Employ validation. "You must really miss your wife. She must have been very important to you." After acknowledging his feelings, redirect: "I have some pictures here of families. Would you like to look at them with me?" or offer a simple, familiar task like folding washcloths.
Environmental Modification: If redirection is successful, ensure his room is well-lit to reduce shadows, reduce noise from the hallway, and perhaps play soft, familiar music from his era. A nightlight is essential.
Collaboration & Evaluation: Document the behavior, interventions tried, and their effectiveness. Report to the oncoming day shift about the sundowning episode. Discuss with the care team if a consistent bedtime routine, increased daytime activity, or review of medications (for those that may contribute to confusion) is needed.
Patient Safety and Precautions:
Restraint Precautions: Physical restraints are a last resort. If, after all interventions, Mr. Johnson is attempting to pull out essential lines (like a central line) and is at imminent risk of harm, you may need to consider mittens or a very brief, closely monitored restraint with a physician's order. You must document the rationale, alternatives tried, and perform checks every 15 minutes (release, assess skin, offer toileting).
Medication Precautions: If PRN medication is administered, monitor closely for oversedation, orthostatic hypotension, and falls. Implement fall precautions (bed alarm, non-skid socks).
Nursing Procedure & Medication FlowNon-Pharmacological De-escalation Procedure:
1. Ensure personal safety and have another staff member aware.
2. Approach non-threateningly, maintain a safe distance.
3. Listen actively and validate the emotion.
4. Offer simple choices to provide a sense of control.
5. Guide to a quieter area and engage in a soothing activity.
6. Continuously assess for escalation or de-escalation.
If Medication is Required (e.g., Lorazepam 0.5 mg PO):
- Check: Verify order, indication (agitation unresponsive to other measures), allergies.
- Assess: Baseline vital signs, level of consciousness, fall risk score.
- Administer: Give orally if possible. If IM route is ordered, use Z-track technique.
- Monitor: Reassess in 30-60 minutes for effect. Monitor for respiratory depression (rate < 12), excessive sedation. Implement strict fall precautions.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, a patient's agitation is a form of communication. Your first job is to 'listen' to what that behavior is saying—fear, pain, need for connection? Using validation and redirection isn't just a technique; it's an act of respect that preserves your patient's humanity. When studying for your boards, don't just memorize 'restraints are bad' — understand the why and the step-by-step alternatives. That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, compassionate, and professional nurse!"
Sundowning — Increased confusion, agitation, and behavioral disturbances in patients with dementia during the late afternoon and evening hours.
Least Restrictive Intervention — A principle of using the method that allows the patient the greatest degree of freedom and autonomy while still ensuring safety, forming a hierarchy of interventions.
Validation Therapy — A therapeutic communication technique that involves acknowledging and accepting the patient's feelings and perceived reality without confrontation or correction.
Physical Restraints — Any manual method or physical/mechanical device that restricts a patient's freedom of movement or access to their body; considered a last-resort intervention.
Circadian Rhythm Disruption — A disturbance in the body's internal 24-hour clock, often implicated in sundowning due to degeneration of brain structures like the suprachiasmatic nucleus in dementia.