A client diagnosed with major NCD is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Which action should be a nursing priority?
1. Consult the psychologist regarding behavior-modification techniques.
2. Medicate the client with prn antianxiety medications.
3. Assess environmental triggers and potential unmet needs.
4. Anticipate the behavior and restrain when pacing begins.
2
Rationale: The priority nursing action is to first medicate the client to avoid injury to self or others. It is important to assess environmental triggers and potential unmet needs in order to address these problems in the future, but interventions to ensure safety must take priority. Because of the cognitive decline experienced in clients diagnosed with this disorder, communication skills and orientation may limit assessment and teaching interventions.
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