# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541805 > language: ko > subject: Growth & Development ## 문제 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? ## 보기 1. Administer prescribed PRN lorazepam to reduce anxiety and agitation 2. Apply soft wrist restraints to prevent the client from leaving the bed 3. Redirect the client's attention using validation therapy and familiar objects **✔ 정답** 4. Place the client in a room closer to the nurses' station for constant observation **정답: 3** ## 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. ## 심화 해설 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].References (research sources) - [1]Sundowning Syndrome in Dementia: Mechanisms, Diagnosis, and Treatment.Research articleReimus M, Siemiński M. (2025) · DOI: 10.3390/jcm14041158 - [2]The Effectiveness and Feasibility of Non-Pharmacological Interventions for Reducing Behavioural and Psychosocial Symptoms of Dementia and Improving Patient Experience in Acute Care Settings: A Systematic Review.Meta-analysis/systematic reviewMcArthur V, Everington S, Wastell E, Ukaji N. (2026) · DOI: 10.3390/bs16050688 - [3]Bridging Gaps in Sundown Syndrome Research: a Scoping Review and Roadmap for Future Multimodal Approaches.Research articleXu Q, Lin FV, Liu Y, Zhao G. (2025) · DOI: 10.1093/arclin/acaf062 ## 임상 시나리오 Managing Sundowning AgitationPrioritizing Non-Pharmacological De-escalation For acute agitation in dementia, non-pharmacological interventions are the first-line standard of care. Initiate validation therapy by acknowledging the client's emotional reality and redirecting with familiar objects or activities before considering medication or restraints. Sundowning is triggered by disrupted circadian rhythms and environmental overstimulation. Reducing noise, closing blinds, and offering a consistent routine in the late afternoon can prevent escalation. CautionAvoid benzodiazepines like lorazepam in older adults with dementia unless absolutely necessary; they increase the risk of paradoxical agitation, falls, and delirium. Physical restraints are a last resort and require frequent reassessment. ## 핵심 개념 - **Sundowning Syndrome** — A neuropsychiatric phenomenon in dementia characterized by increased agitation, confusion, and behavioral symptoms in the late afternoon or evening hours. - **Validation Therapy** — A non-pharmacological communication technique that acknowledges and validates the client's feelings and reality rather than correcting them, reducing anxiety and agitation. - **Non-pharmacological Intervention** — First-line strategies for managing behavioral and psychological symptoms of dementia (BPSD), including redirection, environmental modification, and behavioral approaches. ## 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) - [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) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._