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Zorluk: ZorBehavioral Interventions

A nurse is providing care in a memory-care residential facility. During the late afternoon, a client with moderate Alzheimer's disease becomes severely agitated, pushes their dinner tray onto the floor, and begins crying while demanding to 'go home immediately to cook for my little children.' Which of the following behavioral interventions should the nurse implement first?

  1. A
    Assign an unlicensed assistive personnel to stay with the client and repeatedly explain that they are safe.
  2. B
    Remind the client that their children are now adults and firmly state that they currently live in this facility.
  3. Acknowledge the client's sense of responsibility for their children and invite them to help sort napkins at a quiet table.Cevap
  4. D
    Contact the healthcare provider to request an order for a fast-acting, intramuscular antipsychotic medication.

Cevap

The priority intervention is to use validation therapy by acknowledging the client's feelings and redirecting them to a safe, distracting activity like sorting napkins.
The correct answer utilizes validation therapy, which focuses on the emotion behind the client's words rather than attempting to correct their altered reality. By acknowledging the client's feelings and redirecting them to a purposeful, repetitive task, the nurse safely de-escalates the agitation using the least restrictive behavioral intervention.

Adım Adım Çözüm

1
Analyze the client's presentation and underlying pathology.
The client has moderate Alzheimer's disease and is exhibiting late-afternoon agitation (sundowning) centered around a delusion of needing to care for young children.
Understanding that the agitation stems from a cognitive deficit rather than deliberate defiance changes the intervention approach.
2
Determine the priority goal for the behavioral crisis.
The goal is to de-escalate the agitation using the least restrictive, non-pharmacological methods while maintaining client safety.
Nursing standards require exhausting least-restrictive options before utilizing physical or chemical restraints.
3
Evaluate the proposed interventions against safety and therapeutic guidelines.
Reality orientation (reminding them their children are adults) will increase distress. Medication is a chemical restraint. Delegation to UAP is inappropriate during an acute behavioral crisis.
Eliminating options that are nontherapeutic, restrictive, or outside the scope of practice isolates the correct action.
4
Select the best initial action based on validation therapy principles.
Validation therapy combined with a distracting, purposeful task safely addresses the client's emotional need without triggering further conflict.
This strategy honors the client's current reality and safely redirects their energy.

Anahtar Kavram

Validation Therapy and De-escalation in Dementia
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Konular

Behavioral Interventions

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