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Difficulty: HardMental Health Concepts

At 0200 on a medical-surgical floor, an older adult admitted for severe pneumonia suddenly attempts to climb over the bed rails. The client, who has a history of mild dementia and anxiety, is visibly terrified and shouts about intruders hiding in the ceiling. What is the priority action for the practical nurse to take?

  1. Stay at the bedside, speak in a low and soothing voice, and gently redirect the client back to the center of the bed.Answer
  2. B
    Ask the client why they believe there are intruders while turning on the overhead lights to prove the room is empty.
  3. C
    Request an immediate prescription for a soft vest restraint to prevent a fall and ensure continuous oxygen therapy.
  4. D
    Note the behavior in the chart as an expected complication of nighttime confusion and limit further room entries.

Answer

The practical nurse should remain at the bedside, use a calm and soothing tone, and gently redirect the client back to a safe position in bed.
The client is displaying signs of acute delirium likely secondary to pneumonia, which presents a high risk for injury. The immediate priority is maintaining physical safety using the least restrictive means. Staying at the bedside provides the necessary supervision to prevent a fall, while a calm voice and gentle physical redirection help de-escalate the client's severe agitation without increasing their fear.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is exhibiting sudden-onset severe agitation and visual hallucinations.
Differentiating between the client's baseline mild dementia and the acute onset of delirium (likely triggered by pneumonia) is critical for determining the appropriate intervention.
2
Identify the primary risk to the client.
The client is in immediate danger of falling or injuring themselves by climbing over the bed rails.
In any psychiatric or behavioral emergency, maintaining physical safety is always the highest priority.
3
Select the safest, least restrictive intervention.
Remaining with the client and using verbal and gentle physical redirection prevents injury without escalating the crisis.
Using logic, leaving the room, or immediately applying restraints will either fail to address the safety risk or worsen the client's agitation.

Key Concept

Management of Acute Delirium and Client Safety
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Topics

Mental Health Concepts

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