An elderly patient with multi-infarct dementia is striking out with her arms and kicking at people who walk past in the hall. After making contact with the patient, which intervention would be most appropriate?

Question

a. Administering PRN sedation to calm the patient.
b. State: "You may not hit others; you are safe here.".
c. Distract the patient into playing a board game.
d. State: "I notice you are trying to hit people.".

Answer 1

D
Of the available choices, the next action that should be undertaken is to determine possible causes of the patient's behavior. Pointing out what the nurse is observing focuses the patient on those behaviors and prompts her to elaborate about them, beginning a conversation that could yield the desired assessment data. Sedation often increases disorientation and worsens delirium; it should be a last resort. Setting limits can be helpful in certain situations, but in order to decide whether this applies in this case, the nurse would first need to explore and understand the causes of the patient's behavior. Limit setting and distraction fail to address any underlying causes for the behavior.