Substance Abuse and Abuse Q 66
The nurse can best ensure the safety of a demented client who wanders from the room by:
A. Repeatedly reminding the client of time and place.
B. Explaining the risks of becoming lost.
C. Using soft restraints.
D. Attaching a wander guard sensor band to the client’s wrist.
Correct Answer: D. Attaching a wander guard sensor band to the client’s wrist.
This type of identification band easily tracks the client’s movements and ensures safety while wandering on the unit. Install bed alarms or pressure-sensitive doormats; this provides alarm to alert nurses of movement and help prevent injury to the patient. Avoid using restraints if at all possible. Restraints increase agitation, anxiety, and cause complications of immobility, feelings of powerlessness, and actual increased tendency for wandering.
Option A: Assess patient for presence of wandering behavior, noting time, place, and people with whom he ambulates with. Helps to identify the gravity of the problem and to establish a plan of care. Purposeful wandering occurs when the patient has some intent for his movement, such as to escape boredom, or for exercises. Aimless wandering is usually purposeless and involves disoriented patients who may enter other patients’ rooms and take their belongings. The escapist wandering usually has a destination in mind and is able to leave the premises undetected even though closely supervised.
Option B: Instruct family regarding installing deadbolt locks, fences, locks on gates, and locks on doors and windows. Helps to prevent unsafe exits from home and for the protection of the patient. Instruct the family to notify neighbors and/or local police regarding the patient’s condition and penchant for wandering. Provides awareness of others to prevent the patient from becoming lost or injured.
Option C: Maintain a safe environment and structured routine for the patient. Allow the patient to wander within boundaries in a safe environment. Structure in the patient’s routine may decrease wandering tendencies. Encourage the patient to participate in activities if able to do so. Exercise helps to decrease restlessness and may decrease potential wandering.