The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to
a. reorient the patient to time, place, and person.
b. administer a PRN dose of lorazepam (Ativan).
c. assess for factors that might be causing discomfort.
d. assign unlicensed assistive personnel (UAP) to stay in the patient's room.
ANS: C
Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors like pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.
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