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?

Validation therapy and redirection with familiar objects address emotional needs and maintain safety in sundown syndrome, avoiding restraints or sedation as first-line interventions.

Understanding Sundowning in Dementia
The client’s agitation, attempts to leave, and calling out for deceased family members during the evening hours are classic manifestations of Sundowning Syndrome (SS). This is a neuropsychiatric phenomenon marked by a worsening of behavioral and psychological symptoms of dementia (BPSD) in the late afternoon or evening ^[1][3]. The development of SS relies on a complex interplay of neurodegeneration, disrupted circadian rhythms, and mood disorders ^[1]. Hospitalization in an unfamiliar acute care environment can significantly exacerbate these symptoms, increasing anxiety and agitation, which directly threatens patient safety ^[2].

Prioritizing the First Intervention
The question asks for the first nursing intervention to ensure safety. In managing BPSD, clinical guidance and systematic reviews strongly recommend using non-pharmacological interventions as the first-line approach before considering medication or physical restraints ^[2]. This aligns with a least-restrictive, patient-centered care model.

Analysis of the Correct Answer
Option 3: Redirect the client's attention using validation therapy and familiar objects.
This is the correct initial action. Non-pharmacological interventions, such as behavioral and environmental strategies, are the cornerstone of managing SS and acute agitation in dementia ^[1][2]. A systematic review confirms these approaches are effective and feasible for reducing anxiety and agitation in the acute care setting ^[2]. Validation therapy involves acknowledging the client’s emotional reality (e.g., feelings of loss) rather than correcting their factual errors, which can de-escalate distress. Using familiar objects provides a sense of security and orientation, directly addressing the disorientation that worsens with sundowning ^[1]. This intervention is immediate, non-invasive, and targets the underlying emotional distress driving the behavior.

Why the Other Options Are Not the First Choice
- Option 1: Administering PRN lorazepam is a pharmacological intervention. While it may be necessary if non-pharmacological methods fail, it is not the first-line intervention. Medications carry risks of over-sedation, falls, and worsening confusion in older adults with dementia. Non-pharmacological strategies should be attempted first to reduce agitation ^[2].
- Option 2: Applying soft wrist restraints is a physical restraint and a last resort due to the significant risk of physical and psychological harm, including injury, increased agitation, and loss of dignity. It does not address the cause of the agitation and should only be considered when all other less restrictive measures have failed and the client poses an imminent danger to self or others.
- Option 4: Placing the client closer to the nurses' station for constant observation is an excellent environmental intervention for safety and should be implemented. However, it is a passive safety measure. The first active step a nurse should take when a client is acutely agitated is to attempt to de-escalate the situation through direct therapeutic interaction, such as redirection and validation. Moving the room is a secondary, supportive environmental modification ^[1].