A nurse is caring for a school-age child who has a history of conduct disorder. Which of the following actions should the nurse take while caring for the child? (Select all that apply.).

Choice A rationale:

The nurse should prioritize the safety and well-being of both clients involved. Assisting the client with late-stage Alzheimer's disease to the correct room is important to prevent any further confusion or distress. Alzheimer's disease often causes cognitive impairment, memory loss, and disorientation, which can lead to situations where the individual may not recognize their surroundings or the people around them. Guiding the client back to their own room will help reduce confusion, agitation, and potential conflicts with other clients.

Choice B rationale:

Medicating the patient with antipsychotics is not the most appropriate initial action in this situation. Antipsychotic medications are often used to manage severe behavioral disturbances associated with conditions like schizophrenia or dementia, but their use should be carefully considered due to potential side effects. In this scenario, addressing the immediate situation and guiding the client back to their room is more appropriate than resorting to medication.

Choice C rationale:

Moving the client to a room at the end of the hall is not the best choice because it doesn't directly address the current situation. While changing the client's room might be considered in some cases to reduce agitation or wandering, it's not the immediate action needed when the client is found in another client's bed. Guiding the client to the correct room is the priority.

Choice D rationale:

Placing the client in restraints is not an appropriate choice in this situation. Restraints should only be used as a last resort for ensuring the safety of the client or others when less restrictive interventions have failed. Placing a client with Alzheimer's disease in restraints can be traumatic and lead to increased agitation and psychological distress.

Answer is d. Maintain eye contact with the client and summarize the client’s feelings.

a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.

b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.

c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.

d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.

In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.