Comprehensive exams for Mental Health Q 109
An elderly client with Alzheimer’s disease 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 family 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. Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed. Eliminate or minimize sources of hazards in the environment. Maintain security by avoiding a confrontation that could improve the behavior or increase the risk for injury.
Option A: Telling the client firmly that it is time to get dressed may increase his agitation, especially if the nurse touches him. Assess the degree of impaired ability of competence, emergence of impulsive behavior, and a decrease in visual perception. Impairment of visual perception increases the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers are more aware of the danger.
Option B: Restraints are a last resort to ensure client safety and are inappropriate in this situation. Assess the patient’s surroundings for hazards and remove them. AD decreases awareness of potential dangers, and disease progression coupled with a hazardous environments that could lead to accidents. Help the people closest to identify the risk of hazards that may arise. An impaired cognitive and perceptual disorder are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities or evaluating a particular situation.
Option D: Sedation should be avoided, if possible because it will interfere with CNS functioning and may contribute to the client’s confusion. During the middle and later stages of AD, the patient must not be left unattended. Patients with AD have impaired thinking and cannot rationalize cause and effect. This can result in wandering outside without clothes on, exposure to extreme cold or heat, and may cause dehydration in the long run.