A patient with multi-infarct dementia lashes out and kicks at people who walk past in the hall of a skilled nursing facility. Intervention by the nurse should begin by:
a. gently touching the patient's arm.
b. asking the patient, "What do you need?"
c. saying to the patient, "This is a safe place."
d. directing the patient to cease the behavior.
ANS: C
Striking out usually signals fear or that the patient perceives the environment to be out of control. Getting the patient's attention is fundamental to intervention. The nurse should make eye contact and assure the patient of safety. Once the nurse has the patient's attention, gently touching the patient, asking what he or she needs, or directing the patient to discontinue the behavior may be appropriate.
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