Question

Nurse caring for an older client who has dementia and requires acute care for respiratory infection. The client is agitated and attempting to remove IV.

a) Administer sedative medication
b) Restrain the client
c) Involve family in care
d) Ignore the behavior

Answer 1

In caring for an older client with dementia who is agitated and trying to remove an IV, consider non-pharmacological strategies and involve family members before resorting to sedatives or restraints. Ignoring the behavior is not a safe approach.

Step-by-step explanation:

When caring for an older client with dementia who is agitated and attempting to remove IV, it's important to handle the situation with compassion and safety. Sedatives may be administered, but should be considered carefully given the risks and the client's overall health status. Physical restraints can be used as a last resort when non-restrictive measures have failed and the patient is at risk of harm to themselves or others, however, they require careful monitoring and legal considerations. Involving the family and the healthcare team in care planning can provide support and may help calm the client. Ignoring the behavior is not advisable as it can lead to harm or exacerbation of the client's agitation.

Most Appropriate Actions:

1. Assess the situation and the client's needs.
2. Utilize non-pharmacological interventions to de-escalate the agitation.
3. Involve family members or familiar care providers when possible to reassure and orient the client.
4. Review medications with the care team for possible use of sedatives if absolutely necessary.
5. Employ restraints only as a last resort, ensuring all ethical and legal requirements are met.