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Difficulty: MediumMental Health Concepts

A practical nurse (PN) at an assisted living facility is evaluating an older adult client who recently returned from a family outing. The client's family reports that the client suddenly became highly agitated, failed to recognize them, and began picking at the air. The client has a documented history of mild Alzheimer's disease. Which of the following nursing actions should the PN implement? (Select all that apply.)

  1. Obtain a current set of vital signs, including temperature and oxygen saturation.Answer
  2. B
    Inform the family that sudden, severe cognitive decline is a normal progression of Alzheimer's disease.
  3. Stay with the client in a quiet room to provide continuous observation.Answer
  4. D
    Apply bilateral soft wrist restraints to prevent the client from accidentally injuring themselves.
  5. Ensure the environment is well-lit to reduce shadows and visual misperceptions.Answer
  6. F
    Ask the client, "Why are you picking at the air when there is nothing there?"

Answer

The correct actions are to obtain a current set of vital signs, stay with the client to provide continuous observation, and ensure the environment is well-lit.
The correct actions prioritize client safety, environmental management, and medical assessment. Staying with the client ensures safety. A well-lit room minimizes sensory misperceptions such as illusions. Obtaining vital signs is a crucial data collection step, as acute delirium is frequently caused by physical conditions like urinary tract infections or hypoxia.

Step-by-Step Solution

1
Differentiate between the client's baseline dementia and the current acute presentation.
The nurse identifies that sudden onset of agitation and hallucinations represents acute delirium, not a gradual dementia progression.
Recognizing delirium is critical because it is a medical emergency typically caused by reversible physiological factors (e.g., infection, hypoxia, or medication toxicity).
2
Prioritize immediate safety and data collection.
The nurse stays with the client, ensures a well-lit environment, and obtains vital signs.
These actions address the immediate safety risks of agitation and hallucinations while gathering essential objective data to report to the provider.
3
Avoid non-therapeutic or overly restrictive interventions.
The nurse avoids challenging the client's hallucinations, dismissing the symptoms to the family, or using physical restraints.
Restraints and confrontational communication will escalate the client's distress, and dismissing the symptoms delays necessary medical treatment.

Key Concept

Recognizing and Managing Acute Delirium vs. Dementia
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Topics

Mental Health Concepts

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