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Question

Difficulty: EasyBehavioral Interventions

While completing afternoon rounds on a long-term care unit, a practical nurse observes a confused client attempting to enter another resident's room. The client appears mildly distressed and states, "I need to find my coat so I can catch the bus to work." Which action should the nurse take first?

  1. Gently guide the client away from the doorway while asking them to describe their coatAnswer
  2. B
    Explain logically to the client that they are living in a healthcare facility and no longer go to work
  3. C
    Instruct the client firmly to return to their assigned room to respect the privacy of others
  4. D
    Contact the healthcare provider to obtain a prescription for a mild sedative to reduce wandering

Answer

Gently guide the client away from the doorway while asking them to describe their coat
The correct answer demonstrates the use of validation therapy paired with gentle redirection. By asking the client to describe the coat, the nurse validates the client's current perceived reality without arguing. Simultaneously guiding them away from the doorway safely manages the environmental boundary issue without causing a confrontation.

Step-by-Step Solution

1
Assess the client's current behavioral state and level of escalation.
The client is confused and mildly distressed but not actively aggressive or in immediate physical danger.
Accurate assessment of the client's state determines the appropriate level of intervention required.
2
Apply the principle of least-restrictive behavioral interventions.
Validation therapy and distraction are selected as the initial approach.
Least-restrictive methods de-escalate the situation safely without the use of chemical or physical restraints, which are reserved as last resorts.
3
Implement the intervention by addressing the client's emotional reality while managing the environment.
The nurse asks about the coat to validate feelings and physically guides the client away from the wrong room.
This combination effectively redirects wandering behavior while preventing an emotional crisis.

Key Concept

Validation Therapy and Redirection
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Topics

Behavioral Interventions

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