A client with a medical diagnosis of dementia of Alzheimer's type (DAT) has been increasingly agitated in recent days
As a result, the nurse has identified the nursing diagnosis of "risk for injury related to agitation and confusion" and an outcome of "the client will remain free from injury." What intervention should the nurse use in order to facilitate this outcome?
A) Apply restraints and place the client in seclusion as necessary.
B) Use the least restrictive devices if necessary.
C) Explain to the client the relationship between agitation and injury.
D) Set limits with the client around behavior.
Ans: B
If restrictive devices are necessary, they should be used as a measure of last resort using the least restrictive device possible. Seclusion would be unsafe, and teaching and setting limits are unlikely to be effective interventions with a client who has a cognitive disorder.
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