# A nurse is caring for a 65-year-old client with moderate Alzheimer's dementia in a long-term care facility. During the evening shift, the client becomes increasingly restless and agitated, repeatedly trying to leave the unit while saying, 'My children will be hungry. I must go home and cook their dinner.' The client's children are all adults living independently, and this behavior occurs consistently around 5:00 PM daily. What is the most appropriate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541802 > language: ko > subject: Growth & Development ## 문제 A nurse is caring for a 65-year-old client with moderate Alzheimer's dementia in a long-term care facility. During the evening shift, the client becomes increasingly restless and agitated, repeatedly trying to leave the unit while saying, 'My children will be hungry. I must go home and cook their dinner.' The client's children are all adults living independently, and this behavior occurs consistently around 5:00 PM daily. What is the most appropriate nursing intervention? ## 보기 1. Remind the client that her children are grown adults who can cook for themselves 2. Provide detailed explanations about the current date, time, and location 3. Validate the client's feelings and redirect to a meaningful activity **✔ 정답** 4. Use physical restraints to prevent the client from leaving the unit **정답: 3** ## 해설 Validation therapy and redirection address the emotional needs behind sundowning behaviors in dementia, reducing agitation without confrontation. Other options may increase distress or are inappropriate (e.g., restraints). ## 심화 해설 Understanding Sundowning in Dementia The behavior described is a classic presentation of sundowning syndrome, a phenomenon where behavioral and psychological symptoms of dementia (BPSD) intensify in the late afternoon or early evening. The client’s temporal disorientation and agitation are not a logical choice but a manifestation of neurobiological changes. Research indicates that this diurnal pattern is strongly linked to disruptions in the circadian rhythm, the body’s internal clock [1]. Rather than a conscious attempt to be difficult, the client is likely experiencing an internal, neurologically driven signal of restlessness and a fragmented memory trace from her past role as a caregiver, which is triggered by the time of day and reduced environmental light. Why Reality Orientation and Restraints Are Inappropriate Options 1 and 2 rely on reality orientation, which is contraindicated in moderate to late-stage dementia. Confronting the client with the fact that her children are adults directly challenges her perceived reality, which is rooted in long-term memory. This approach often escalates anxiety and agitation because the client cannot retain or process the logical correction. Similarly, providing detailed explanations about the date and time demands cognitive functions that are significantly impaired. These approaches fail because they do not address the underlying emotional distress or the neurobiological trigger. Option 4, using physical restraints, is a violation of the client’s rights and safety, drastically increasing the risk of injury, psychological trauma, and worsening agitation; it is never an appropriate first-line intervention for sundowning. The Therapeutic Rationale for Validation and Redirection The correct intervention is to validate the client's feelings and redirect to a meaningful activity. The core principle here is validation therapy, which accepts the client’s emotional experience as real. By saying, “You’re worried about your children being hungry,” the nurse acknowledges the feeling of care and responsibility, which reduces the client’s anxiety and the need to defend her reality. Following validation with redirection to a familiar, purposeful task—such as folding napkins, setting a table, or sorting kitchen items—engages her procedural memory and preserved abilities. This approach is directly supported by the understanding that managing BPSD effectively requires non-pharmacological, person-centered strategies that modulate environmental and behavioral triggers rather than challenging the patient’s cognition . Since the agitation is linked to a predictable circadian pattern and a specific time of day, a structured, meaningful activity at this hour can help regulate the behavioral symptom by providing a sense of purpose and environmental stability [1,2]. Modern approaches even explore how personal light exposure can be measured and modulated to stabilize these circadian-driven symptoms, further emphasizing the biological underpinning of the behavior that requires therapeutic, not confrontational, management .References (research sources) - [1]Light, sleep-wake rhythm, and behavioural and psychological symptoms of dementia in care home patients: Revisiting the sundowning syndrome.Research articleGuu TW, Aarsland D, Ffytche D. (2022) · DOI: 10.1002/gps.5712 ## 임상 시나리오 Managing Sundowning in DementiaValidation and Redirection over Reality Orientation When a client with dementia exhibits sundowning (late-day agitation), the priority is to validate their feelings, not their facts. Acknowledge the emotion behind the statement (e.g., "You sound worried about your children") to reduce distress. Immediately follow validation with redirection to a meaningful, calming activity that aligns with their past role, such as folding napkins, sorting socks, or listening to familiar music. This engages their preserved procedural memory. CautionAvoid reality orientation (correcting them) or detailed explanations, as these increase anxiety and agitation in moderate-to-severe dementia. Physical restraints are contraindicated and violate patient rights. ## 핵심 개념 - **Sundowning** — A phenomenon in dementia where behavioral symptoms like agitation and confusion intensify in the late afternoon or early evening, linked to circadian rhythm disruptions. - **Validation Therapy** — A communication technique that acknowledges the person's emotional reality and feelings rather than correcting their factual inaccuracies, reducing distress. - **Redirection** — A nursing intervention that shifts a person's focus from a distressing thought or behavior to a more neutral or pleasant, meaningful activity. - **Reality Orientation** — A technique of presenting information about time, place, and person; often contraindicated in moderate-to-severe dementia as it can cause frustration and agitation. - **Circadian Rhythm** — The body's internal 24-hour clock that regulates the sleep-wake cycle; its disruption is a major neurobiological factor in sundowning. ## 같은 주제 문제 - [A nurse is assessing an 82-year-old client in a long-term care facility who has been exhib…](https://mymerci.kr/pages/nclex_q.php?qn_id=541800) - [A nurse is assessing an 82-year-old client in a long-term care facility who has been exhib…](https://mymerci.kr/pages/nclex_q.php?qn_id=541801) - [An 82-year-old client with mild cognitive impairment has been experiencing increased confu…](https://mymerci.kr/pages/nclex_q.php?qn_id=541803) - [A nurse is caring for a 75-year-old client with Lewy body dementia who has been increasing…](https://mymerci.kr/pages/nclex_q.php?qn_id=541804) - [An 82-year-old client with moderate dementia is admitted to the medical unit. 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