# Situation: An 80-year-old woman with moderate Alzheimer disease is admitted to the medical ward for dehydration. She lives with her daughter. Her medications are donepezil 10 mg at bedtime and metoprolol 50 mg twice daily for hypertension. Every day at about 17:00 she becomes more confused and tries to leave the ward. Which plan is MOST likely to reduce this behavior?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630424  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: An 80-year-old woman with moderate Alzheimer disease is admitted to the medical ward for dehydration. She lives with her daughter. Her medications are donepezil 10 mg at bedtime and metoprolol 50 mg twice daily for hypertension.

Every day at about 17:00 she becomes more confused and tries to leave the ward. Which plan is MOST likely to reduce this behavior?

## 보기

1. A morning walk in daylight, and coffee with her afternoon snack
2. A morning walk in daylight, and a 2-hour nap after lunch
3. Rest in bed in a dim, quiet room through the afternoon
4. A morning walk in daylight, and a quiet, dim evening routine **✔ 정답**

**정답: 4**

## 해설

Worsening confusion late in the day is sundowning. Daytime activity and daylight exposure, limited daytime napping, and reduced evening stimulation and caffeine support a normal sleep–wake rhythm. Only the plan that pairs daylight activity with a calm evening avoids every trigger.

## 심화 해설

The plan most likely to reduce the behavior
Every day at about 17:00 she becomes more confused and tries to leave the ward. Worsening confusion late in the day is sundowning. It is reduced by supporting a normal sleep–wake rhythm: daytime activity and daylight exposure, limited daytime napping, and reduced evening stimulation and caffeine. Only the plan that pairs a morning walk in daylight with a quiet, dim evening routine avoids every trigger.

Why sundowning happens
Alzheimer disease damages the brain structures that regulate the circadian rhythm. As a result, the internal clock becomes weaker and the distinction between day and night blurs. Late afternoon and evening bring fading light, fatigue, shift changes, and increased noise, all of which can overwhelm a person with dementia. Hospitalization adds an unfamiliar environment and disrupted routines. Strengthening daytime cues with light and activity, and making evenings calm and predictable, helps the brain maintain a clearer rhythm.

| Plan | Helpful element | Trigger present | Verdict |
| --- | --- | --- | --- |
| Morning daylight walk; coffee with afternoon snack | Daylight activity | Late caffeine | Incomplete |
| Morning daylight walk; 2-hour nap after lunch | Daylight activity | Long daytime nap | Incomplete |
| Dim, quiet room all afternoon | — | Loss of light and activity cues | Incorrect |
| Morning daylight walk; quiet, dim evening | Daylight and calm evening | None | Best |

Why the other plans fall short
Caffeine with the afternoon snack adds to evening restlessness and poor sleep. A two-hour nap after lunch disturbs the sleep–wake cycle and makes nighttime sleep and evening confusion worse. Resting in a dim, quiet room all afternoon removes the daytime light and activity cues that the brain needs, worsening the circadian disturbance. Each of these plans contains at least one trigger.

Additional nursing measures
The nurse keeps a consistent routine and familiar caregivers, ensures adequate hydration and pain control, involves the daughter in evening activities if possible, uses calm reassurance and redirection rather than confrontation, and ensures safety measures for a client who tries to leave. Physical restraints and sedatives are avoided as first-line measures.

Exam takeaway
Key point Sundowning responds to daylight and activity during the day plus a calm, low-stimulation evening, with limited naps and no late caffeine. Choose the option that avoids every trigger.

## 임상 시나리오

Managing SundowningStrengthen the day, calm the evening
Worsening confusion and agitation late in the day is sundowning, caused by a disrupted sleep–wake rhythm in dementia.

Daylight exposure and activity in the morning, limited daytime napping, no late caffeine, and a quiet, dim evening routine support a normal circadian rhythm and reduce evening confusion.

CautionLong naps, late coffee, and afternoons in a dark room each worsen sundowning. Avoid restraints and use calm redirection.

## 핵심 개념

- **Sundowning** — Increased confusion, agitation, or wandering in the late afternoon or evening in people with dementia.
- **Circadian rhythm** — The body's roughly 24-hour internal clock that regulates sleep and wakefulness.
- **Redirection** — Gently guiding a person with dementia toward a different activity to reduce distress.
- **Alzheimer disease** — A progressive neurodegenerative disease causing memory loss and decline in thinking and behavior.

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