Which of the following actions should the nurse take to address the safety needs of an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused?

Choice A reason:

Rewarding the client for their change in behavior may seem positive, but it is not an appropriate nursing action in this context. It could reinforce the idea that only certain behaviors receive attention, which is not conducive to the therapeutic process.

Choice B reason:

Asking the client why their behavior has changed is not the most appropriate initial action. While understanding the client's perspective is important, it is more crucial to assess the situation for safety concerns, as sudden mood changes can sometimes precede impulsive actions.

Choice C reason:

Encouraging the family to take the client out of the facility for short periods of time is not advisable without a proper assessment of the client's stability and readiness for such activities. It is essential to ensure that the client is safe and that their treatment plan is being followed.

Choice D reason:

Monitoring the client's whereabouts at all times is the most appropriate action. A sudden change in mood can be a warning sign of increased risk for impulsive behavior, including self-harm or suicide. Continuous monitoring ensures the client's safety and allows for immediate intervention if necessary.

Choice A Reason:

The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband" is non-therapeutic because it shifts the focus from the client to the nurse. This response demonstrates sympathy rather than empathy. Sympathy involves sharing one's own experiences and feelings, which can make the client feel unheard and invalidated. The nurse's role is to provide support and understanding without making the conversation about themselves.

Choice B Reason:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you" is more therapeutic. It acknowledges the client's feelings and offers support without shifting the focus to the nurse. This response shows empathy by validating the client's emotions and providing a comforting presence.

Choice C Reason:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is therapeutic as it recognizes the client's feelings and invites them to express their thoughts and emotions. This approach encourages open communication and helps the client feel understood and supported.

Choice D Reason:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" is also therapeutic. It acknowledges the client's emotional state and offers a practical solution to help manage their anxiety. This response shows empathy and provides an option for addressing the client's immediate needs.