# A nurse is caring for a 75-year-old client with Lewy body dementia who has been increasingly agitated and attempting to leave the unit. Which nursing intervention should be the nurse's first priority to ensure client safety? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541804 > language: ko > subject: Growth & Development ## 문제 A nurse is caring for a 75-year-old client with Lewy body dementia who has been increasingly agitated and attempting to leave the unit. Which nursing intervention should be the nurse's first priority to ensure client safety? ## 보기 1. Implement validation therapy and provide a calm, structured environment **✔ 정답** 2. Apply soft wrist restraints to prevent the client from wandering 3. Administer prescribed PRN sedative medication immediately 4. Place the client in a room closer to the nurses' station for constant observation **정답: 1** ## 해설 Validation therapy and a calm, structured environment address emotional needs and safety without restraints, which is the priority for agitated dementia patients. Restraints, sedatives, or room placement are less therapeutic or restrictive alternatives. ## 심화 해설 Understanding the Priority: Safety in Lewy Body Dementia When caring for a client with Lewy body dementia (LBD) exhibiting agitation and exit-seeking behavior, the nurse's first priority is to de-escalate the situation using the least restrictive, non-pharmacological approach. This aligns with the foundational NCLEX-RN principle of maintaining client safety while preserving autonomy and dignity. The correct intervention is to implement validation therapy and provide a calm, structured environment. Why Validation and a Structured Environment are First-Line Agitation and wandering in LBD are often manifestations of unmet emotional needs, fear, or disorientation rather than intentional disruptiveness. Emotion-oriented interventions (EOIs), which include validation therapy, directly address these underlying psychological and emotional triggers. A systematic review and meta-analysis of randomized controlled trials confirms that EOIs are effective non-pharmacological approaches designed to address the emotional and psychological needs of people with dementia [2]. Rather than confronting the client’s reality, validation therapy acknowledges their feelings, reducing the fear and anxiety that fuel the desire to leave. Creating a calm, structured environment further minimizes overstimulation, a common trigger for behavioral and psychological symptoms in LBD. This approach is a cornerstone of high-quality nursing care for neurological disorders, where addressing the patient's immediate psychosocial context is critical for positive outcomes . Analyzing the Incorrect Options - Option 2: Apply soft wrist restraints. Physical restraints are a restrictive intervention and are never a first-line choice. Guidelines for geriatric care emphasize the need for tailored management that considers multimorbidity and frailty, explicitly cautioning against interventions that can cause physical harm, increased agitation, or loss of function . Restraints can escalate fear and combativeness in a client with dementia, leading to injury. - Option 3: Administer prescribed PRN sedative medication immediately. While PRN medications have a role, they are not the initial priority before trying non-pharmacological de-escalation. Sedatives can have paradoxical effects, increase the risk of falls, and worsen cognitive clouding, particularly in the frail geriatric population where evidence-based recommendations guide decision-making to avoid such iatrogenic harm . The nurse must first attempt to manage the behavior environmentally and interpersonally. - Option 4: Place the client in a room closer to the nurses' station. This is an appropriate environmental modification for safety, but it is a passive surveillance strategy. It does not actively address the client's immediate emotional distress and agitation. The priority is to intervene therapeutically to calm the client’s agitation at its source. Once the client is calmer, relocating them closer to the station is a sound secondary prevention measure. Connecting to the Underlying Pathology In LBD, fluctuations in cognition and visual hallucinations are core features that directly contribute to agitation and wandering. A client may attempt to leave the unit because they misperceive a threat or believe they need to fulfill a past obligation. Validation therapy works by entering their reality, reducing the terror that drives the behavior. This is a more immediate and therapeutic safety measure than simply observing the behavior or chemically/physically restricting it. The evidence supports that addressing sleep disturbances and behavioral symptoms with structured, non-pharmacological strategies is both clinically effective and preferred over immediate pharmacotherapy in dementia care .References (research sources) - [2]Effects of emotion-oriented interventions on cognitive, behavioral, and psychological symptoms in people with dementia: a systematic review and meta-analysis of randomized controlled trials.Meta-analysis/systematic reviewDuarte-Díaz A, Álvarez-Pérez Y, Ramos-García V, Perestelo-Pérez L, Aymerich M, Robles N, Carrion C. (2025) · DOI: 10.1186/s12877-025-06804-w ## 임상 시나리오 Clinical Safety Protocol When a client with Lewy body dementia (LBD) exhibits agitation and exit-seeking behavior, the nurse's immediate priority is de-escalation using the least restrictive, non-pharmacological strategy. This approach is mandated to preserve client autonomy and prevent harm, as physical or chemical restraints can exacerbate symptoms and lead to adverse outcomes in LBD. Priority Nursing Action - Approach the client calmly and use validation therapy. Acknowledge their expressed emotions (e.g., "I see you are upset and want to go home. Tell me about your home.") without confronting their reality. - Assess for immediate physiological triggers (pain, infection, constipation, urinary retention) that may be causing the agitation. - Modify the environment to reduce overstimulation: lower noise levels, dim bright lights, and remove clutter to create a structured, predictable space. - Offer a meaningful diversion or activity, such as folding towels, listening to familiar music, or a supervised walk in a secure area. Restraint and Medication PrecautionsSoft wrist restraints and immediate PRN sedative administration are not first-line interventions. Restraints increase the risk of injury, agitation, and loss of dignity. Antipsychotic and sedative medications carry a black box warning for increased mortality in elderly patients with dementia and can cause severe sensitivity reactions in LBD. These measures are reserved for situations where the client poses an imminent risk of harm to self or others and all non-pharmacological interventions have failed. Rationale for Environmental ManagementPlacing the client in a room closer to the nurses' station for constant observation is a restrictive environmental intervention that does not directly address the underlying emotional distress. While increased monitoring may be a component of a safety plan, it should be implemented after initial de-escalation attempts and in combination with therapeutic communication. The primary goal is to resolve the agitation by meeting the client's unmet needs, not merely containing the behavior. ## 핵심 개념 - **Validation therapy** — A communication technique that acknowledges and accepts the feelings and reality of a person with dementia to reduce anxiety and agitation. - **Lewy body dementia** — A progressive neurodegenerative disorder characterized by abnormal protein deposits, cognitive fluctuations, visual hallucinations, and parkinsonism. - **Least restrictive intervention** — A legal and ethical principle requiring the use of the most freedom-preserving method of care that ensures safety before applying more restrictive measures. - **Non-pharmacological intervention** — Therapies and environmental modifications used as first-line treatment for behavioral symptoms of dementia, avoiding medication side effects. ## 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) - [A nurse is caring for a 65-year-old client with moderate Alzheimer's dementia in a long-te…](https://mymerci.kr/pages/nclex_q.php?qn_id=541802) - [An 82-year-old client with mild cognitive impairment has been experiencing increased confu…](https://mymerci.kr/pages/nclex_q.php?qn_id=541803) - [An 82-year-old client with moderate dementia is admitted to the medical unit. 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