Medical Surgical Alzheimer’s Disease #2

Question

An Alzheimer’s client keeps getting out of her bed and wandering around the hall and wringing her hands. Which intervention by the nurse would be most therapeutic?

Answers

  1. Call the on-call provider for a medication order to sedate the client.
    • Rationale:

      This answer is not correct because the client is displaying nonaggressive behaviors and does not seem like a threat to herself or anyone. Medication to sedate the client is considered a chemical restraint and should only be used in an emergency situation.

  2. Utilize the order for soft wrist restraints to keep the client in bed.
    • Rationale:

      This answer is not correct because the use of soft wrist restraints should only be utilized if the client is pulling at drainage tubes or IV lines or demonstrating self-destructive behavior. Restraints should always only be used as a last resort

  3. Contact the client's family member to come and sit with the client.
    • Rationale:

      This answer is not correct because it is unreasonable and/or a family member may not be available or equipped to caretake the client. The client was placed in the facility’s care and it is the responsibility of the nurse to care for the client.

  4. Ask the client to fold some towels beside her while she does her charting.
    • Rationale:

      This answer is correct because it is the least restrictive measure. Providing a diversional activity can increase the client’s self esteem. The client may also feel it is a meaningful task since she is “helpingâ€ the nurse. Reorienting the client to this task provides motor stimulation for the client.

Overview

Alzheimer’s clients may display non-aggressive behaviors such as pacing, restlessness, or wringing their hands.With these behaviors, the most therapeutic approach would involve the client participating in a motor activity.

Explanation

Learning Outcomes

Alzheimer’s clients may display non-aggressive behaviors such as pacing, restlessness or wringing their hands.With these behaviors, the most therapeutic approach would involve the client participating in a motor activity, such as folding towels. A task repetitious in nature may decrease anxiety in the client. It also allows the client some authority in their immediate environment. Physical and chemical restraints are always used as a last resort. Restraints contribute to increased confusion and injury. Until the client’s behavior becomes aggressive or self-destructive, the diversional activity approach promotes trust between the nurse and client.

Test Taking Tip

Always choose the least restrictive or least invasive method of treatment first.

Video Rationale