A nurse in an acute care facility is caring for a client who has Alzheimer's disease. The client is pacing in the hallway and states, "I am trying to get to work, and I can't be late!" Which of the following responses should the nurse make?

"Would you like me to get some medication to calm you down?"

"You don't work anymore. Let's go sit down and talk."

"Would you like to go to your room for a nap now?"

"I'll walk with you for a while. Tell me about your work."

Answer and Explanation

The Correct Answer is D

A. "Would you like me to get some medication to calm you down?": Offering medication immediately does not address the underlying anxiety or disorientation. Non-pharmacologic interventions should be attempted first in clients with Alzheimer’s disease unless safety is at immediate risk.

B. "You don't work anymore. Let's go sit down and talk.": Confronting the client with reality can increase confusion, anxiety, and agitation. Clients with Alzheimer’s disease respond better to validation rather than correction of their perceptions.

C. "Would you like to go to your room for a nap now?": Redirecting to rest may help in some situations, but it does not validate the client’s feelings or engage them in a meaningful way. The client may resist if the suggestion does not acknowledge their current concern.

D. "I'll walk with you for a while. Tell me about your work.": Walking alongside the client and engaging in conversation validates their feelings, reduces agitation, and provides safe physical activity. This approach supports emotional connection, reduces anxiety, and prevents escalation of behavioral symptoms.

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Correct Answer is A

Explanation

A. The client is experiencing command hallucinations: Command hallucinations pose an immediate risk because the client may be instructed to harm themselves or others. Ensuring safety is always the highest priority in psychiatric care, making this finding the most urgent concern for the nurse to address first.

B. The client is refusing to take their medication: Medication refusal can worsen symptoms over time, but it does not present an immediate threat to the client or others. While important to address, it is secondary to safety concerns posed by command hallucinations.

C. The client is unable to initiate personal grooming tasks: Difficulty with self-care affects the client’s hygiene and overall health but does not create an immediate risk of harm. Interventions to assist with grooming are supportive and lower priority compared to safety threats.

D. The client is experiencing flight of ideas: Flight of ideas reflects pressured speech or rapid thought patterns, which can indicate mania or acute exacerbation. While it requires monitoring and intervention, it does not present an immediate danger compared to command hallucinations.

A. "Why are you not following your treatment plan?" B. "Let's discuss the consequences of your actions." C. "You know that manipulation is not the appropriate thing to do." D. "I can request that your provider decrease the restriction."

Correct Answer is B

Explanation

A. "Why are you not following your treatment plan?": Asking “why” questions can be perceived as judgmental or confrontational, which may escalate defensive or manipulative behaviors. It does not promote reflection or understanding of consequences.

B. "Let's discuss the consequences of your actions.": Focusing on the consequences helps the client understand the impact of their behavior and encourages accountability. This approach maintains professional boundaries while promoting insight and adherence to the treatment plan.

C. "You know that manipulation is not the appropriate thing to do.": Labeling the behavior as inappropriate can be perceived as shaming and may provoke resistance or further manipulation. It is less effective than guiding the client toward understanding consequences.

D. "I can request that your provider decrease the restriction.": Allowing the client to bypass established restrictions undermines boundaries and reinforces manipulative behavior. Maintaining consistency and following established protocols is essential for treatment effectiveness and safety.

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A nurse in an acute care facility is caring for a client who has Alzheimer's disease. The client is pacing in the hallway and states, "I am trying to get to work, and I can't be late!" Which of the following responses should the nurse make?

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