# The charge nurse observes care for a client with dementia who becomes agitated. Which nursing actions require immediate follow-up? Highlight the actions that may escalate distress or bypass safer assessment. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=497306&lang=en > language: en > subject: Mental Health Concepts > category: PSI ## Question The charge nurse observes care for a client with dementia who becomes agitated. Which nursing actions require immediate follow-up? Highlight the actions that may escalate distress or bypass safer assessment. Nurses' Notes 1840: The client with moderate dementia begins pacing and says, “I need to pick up my children.” One nurse responds by repeatedly correcting the client's belief and arguing that the children are adults. A second nurse approaches slowly and speaks in a calm voice while reassuring the client about immediate safety. At 1845, staff prepare for the scheduled bath. The first nurse insists that bathing continue while the client cries and pulls away. The assigned nurse pauses and checks for pain, urinary urgency, constipation, hunger, and fatigue. Environmental services is asked to wait, and television volume and hallway noise are reduced near the room. The client is offered a familiar folding activity and a warm drink. Another staff member suggests that wrist restraint be applied before possible physical or environmental triggers are assessed. When the client swings an arm, staff maintain a safe distance and move other clients away. At 1855, the care plan shows that the usual evening routine and familiar caregiver are maintained when possible. The nurse also reports the sudden behavior change during the current shift for evaluation of infection or medication effects. The client accepts the drink and sits with the familiar caregiver. The team documents the trigger assessment and response without forcing the bath. ## Explanation Arguing about the client’s belief, forcing bathing despite distress, and using restraint before assessing triggers require follow-up. Calm reassurance, safety, reduced stimulation, and evaluation of pain or other needs are preferred first. ## In-depth explanation Quick answer Highlight repeatedly correcting and arguing with the client, insisting on the bath while distress increases, and applying restraint before assessing a cause. These responses can intensify fear and skip reversible physical or environmental triggers. Why this is correct Agitation in dementia often has a reason, such as pain, constipation, fatigue, medication effects, noise, or being pushed into a difficult activity. A calm tone, reassurance, reduced stimulation, redirection, safe distance, and medical assessment address needs while using the least restrictive response.[2] Easy analogy or mental picture Picture agitation as a smoke alarm: first look for heat, smoke, or a faulty sensor instead of shouting at the alarm. The image encourages cause-finding, but dangerous aggression still requires immediate protection of the client and others. Memory hook Calm, check needs, reduce triggers, redirect, protect. NCLEX decision rule With dementia-related agitation, ensure safety and assess unmet needs or acute illness before medication or restraint; avoid arguing, quizzing, or forcing an activity that is increasing distress. Why the other choices are wrong Speaking calmly, checking for pain and constipation, lowering noise, offering a familiar activity, keeping a safe distance during striking, maintaining routine, and reporting a sudden change all address safety or likely causes without confrontation.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]NIA: Coping With Agitation and AggressionNational Institute on Aging ## Related questions - [A client hospitalized for depression says, "My family would be better off without me." Whi…](https://mymerci.kr/pages/nclex_q.php?qn_id=393687&lang=en) - [A client with schizophrenia says, "The voices are telling me to do something bad." Which r…](https://mymerci.kr/pages/nclex_q.php?qn_id=394025&lang=en) - [A client arrives with bruises at different stages of healing. The partner answers all ques…](https://mymerci.kr/pages/nclex_q.php?qn_id=394098&lang=en) - [A client with anorexia nervosa is admitted with dizziness, heart rate 44/min, and potassiu…](https://mymerci.kr/pages/nclex_q.php?qn_id=394175&lang=en) - [A hospitalized client with major depression says, "Everyone would be better off if I did n…](https://mymerci.kr/pages/nclex_q.php?qn_id=394754&lang=en) - [A client with acute mania is pacing, speaking rapidly, and trying to enter other clients' …](https://mymerci.kr/pages/nclex_q.php?qn_id=397175&lang=en) - [A client on an inpatient unit is 18 hours after the last alcohol intake and is tremulous, …](https://mymerci.kr/pages/nclex_q.php?qn_id=397292&lang=en) - [An adult who reports a recent sexual assault wants medical treatment but is unsure about e…](https://mymerci.kr/pages/nclex_q.php?qn_id=397294&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=497306&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=497306&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=497306&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=497306&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=497306&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._