# A nurse is caring for a 60-year-old client with dementia who is experiencing an acute behavioral crisis with confusion and wandering. Which nursing intervention should be implemented first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543437 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a 60-year-old client with dementia who is experiencing an acute behavioral crisis with confusion and wandering. Which nursing intervention should be implemented first? ## 보기 1. Administer prescribed PRN antipsychotic medication immediately 2. Ensure environmental safety by removing potential weapons and calling for additional staff support **✔ 정답** 3. Attempt to de-escalate the situation through therapeutic communication techniques 4. Place the client in physical restraints to prevent harm to others **정답: 2** ## 해설 Ensuring environmental safety by removing weapons and calling for staff is priority when a client threatens violence. De-escalation, medication, or restraints are secondary after safety is established. ## 심화 해설 Understanding the Clinical Scenario This question presents a client with dementia in an acute behavioral crisis involving confusion and wandering. In NCLEX-RN prioritization, when a client exhibits potential for harm to self or others, the immediate focus must be on safety. The core of this scenario is managing a volatile situation where the client's cognitive impairment prevents rational redirection, making environmental hazards a critical concern. Prioritizing Safety Over Pharmacological or Physical Restraint The correct first intervention is to ensure environmental safety by removing potential weapons and calling for additional staff support. This aligns with the foundational nursing principle of the least restrictive intervention. In the context of severe behavioral and psychological symptoms of dementia (BPSD), as highlighted in the study by Murano and Foureur, specialized cognitive-behavioral units (CBUs) are designed to manage such crises by focusing on structured, safe environments rather than immediate chemical or physical restraint [1]. The presence of additional staff is not merely for physical control but to provide a "show of support" that can de-escalate a situation through non-confrontational means, which is a key element in the ethical care of these patients [1]. Why Other Options Are Not the First Priority - Administering PRN antipsychotic medication is a chemical restraint. While it may become necessary, it is not the first-line action. The clinical ethics perspective from the CBU study emphasizes exhausting environmental and behavioral strategies before resorting to medication, which can have significant side effects in older adults with dementia [1]. The nurse must first ensure the immediate physical environment is safe to prevent injury during the escalation period before the medication takes effect. - Attempting therapeutic communication is a valuable de-escalation technique, but in an acute behavioral crisis with a client who is confused and wandering, their ability to process complex verbal cues is severely diminished. Safety must be physically established first; you cannot effectively communicate with a client who is about to pick up a hazardous object. - Placing the client in physical restraints is the most restrictive intervention and carries significant risks, including injury, agitation, and psychological trauma. The ethical framework for managing severe BPSD, as explored in the CBU model, advocates for a milieu that minimizes coercion [1]. Restraints are a last resort when all other safety and de-escalation measures have failed and there is an imminent, unavoidable risk of harm. Connecting to the Underlying Pathophysiology and Ethical Care Model The client's wandering and confusion stem from neurodegenerative changes that impair judgment, impulse control, and environmental interpretation. In a crisis, the nurse must act as the client's external safety net. The CBU model’s approach, which involves a structured environment and trained staff, is built on the premise that the physical and social environment can be modified to reduce triggers for BPSD and manage crises safely [1]. Removing potential weapons (e.g., scissors, IV poles, heavy objects) directly addresses the immediate risk of harm, while calling for additional staff creates a safer dynamic for potential non-physical redirection. This sequence—securing the environment, then using a team-based, least-restrictive approach—is the clinical standard for ethically and effectively managing an acute behavioral crisis in dementia [1].References (research sources) - [1]Severe behavioral and psychological symptoms of dementia: A clinical ethics study of cognitive-behavioral units in France.Research articleMurano MC, Foureur N. (2026) · DOI: 10.1177/13872877261427494 ## 임상 시나리오 Managing Acute Behavioral Crisis in DementiaPrioritizing Safety with the Least Restrictive Approach The immediate priority is environmental safety. Scan the area and remove any potential weapons or hazardous objects. Call for additional staff support not just for physical control, but to create a non-confrontational show of support that can aid de-escalation. This follows the principle of the least restrictive intervention. A structured, safe environment is the foundation of care in specialized dementia units. Physical or chemical restraints are secondary measures, used only when environmental and behavioral strategies are insufficient. CautionDo not attempt therapeutic communication as the first action during an acute crisis with severe confusion. The client's cognitive impairment prevents rational redirection, making immediate safety measures the top priority. ## 핵심 개념 - **Least Restrictive Intervention** — A guiding principle requiring the use of the least confining or controlling measure possible to manage a client's behavior, prioritizing verbal and environmental strategies over physical or chemical restraints. - **Behavioral and Psychological Symptoms of Dementia (BPSD)** — A range of non-cognitive symptoms, including agitation, aggression, wandering, and psychosis, that frequently occur in individuals with dementia. ## 같은 주제 문제 - [A nurse is conducting an initial assessment of a 28-year-old client who presents to the em…](https://mymerci.kr/pages/nclex_q.php?qn_id=543430) - [A nurse is providing crisis intervention for a client experiencing an acute psychiatric cr…](https://mymerci.kr/pages/nclex_q.php?qn_id=543431) - [A nurse is working with a client experiencing an acute crisis following a recent job loss …](https://mymerci.kr/pages/nclex_q.php?qn_id=543432) - [A nurse is working with a client experiencing an acute psychological crisis after a trauma…](https://mymerci.kr/pages/nclex_q.php?qn_id=543433) - [A nurse is working with an adolescent client experiencing an acute psychological crisis af…](https://mymerci.kr/pages/nclex_q.php?qn_id=543434) - [A nurse is providing crisis intervention for a 35-year-old client experiencing an acute ps…](https://mymerci.kr/pages/nclex_q.php?qn_id=543435) - [A nurse is working with a 22-year-old college student experiencing an acute panic attack w…](https://mymerci.kr/pages/nclex_q.php?qn_id=543436) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._