Alzheimer’s Delirium and Dementia Q 63
Mrs. Jordan is an elderly client diagnosed with Alzheimer’s disease. She becomes agitated and combative when a nurse approaches to help with morning care. The most appropriate nursing intervention in this situation would be to:
A. Tell the client firmly that it is time to get dressed.
B. Obtain assistance to restrain the client for safety.
C. Remain calm and talk quietly to the client.
D. Call the doctor and request an order for sedation.
Correct Answer: C. Remain calm and talk quietly to the client.
Maintaining a calm approach when intervening with an agitated client is extremely important. Use a rather low voice and speak slowly to patients to increase the possibility of understanding. Divert attention of the client when agitated or behaving dangerously like getting out of bed by climbing the fence bed to promote safety and prevent risk of injury.
Option A: Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Avoid or terminate emotionally charged situations or conversations. Avoid anger and expectation of the patient to remember or follow instructions. Do not expect more than the patient is capable of doing. Catastrophic emotional responses are prompted by task failure when the patient feels expected to perform beyond ability and becomes frustrated and angry. Responding calmly to the patient validates feelings and causes less stress.
Option B: Restraints are a last resort to ensure client safety and are inappropriate in this situation. Assess the patient for reversible or irreversible dementia, causes, ability to interpret environment, intellectual thought processes, memory loss, disturbances with orientation, behavior, and socialization. Determines type and extent of dementia to establish a plan of care to enhance cognition and emotional functioning at optimal levels.
Option D: Sedation should be avoided, if possible, because it will interfere with CNS functioning and may contribute to the client’s confusion. Maintain consistent scheduling with allowances for patient’s specific needs, and avoid frustrating situations and overstimulation. Prevents patient agitation, erratic behaviors, and combative reactions. Scheduling may need revision to show respect for the patient’s sense of worth and to facilitate completion of tasks.