Today’s NCLEX-RN® question of the day focuses on how a nurse should handle an agitated client diagnosed with dementia.
The nurse in the medical-surgical unit is caring for a client diagnosed with dementia. The client becomes agitated and starts to yell at the nurse and other hospital staff. Which is the priority nursing intervention?
A. Ignoring the client until the behavior subsides
B. Encouraging the client to get involved in unit activities
C. Confronting the client about the behavior
D. Ensuring the safety of clients and staff
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The correct answer to today’s NCLEX-RN® Question is…
D. Ensuring the safety of clients and staff
Rationale: Safety for all of the clients and staff on the unit should be the nurse’s priority.
Main takeaway
Safety for all of the clients and staff on the unit should be the nurse’s priority. Therefore, the nurse should plan interventions to avoid escalation of the behavior of aggressive clients. The nurse should not ignore or confront the client because these actions may escalate the agitation. Encouraging the client’s involvement in unit activities may help prevent agitation, but, after agitation occurs, it may just escalate the behavior.
Incorrect answer explanations
A. Ignoring the client until the behavior subsides
Rationale: The nurse should plan interventions to avoid escalation of the client’s behavior. Ignoring the client is not the priority nursing intervention because this may allow the agitation to escalate.
B. Encouraging the client to get involved in unit activities
Rationale: The nurse should plan interventions to avoid escalation of the client’s behavior. Encouraging client involvement in activities may be effective in preventing agitation from developing, but if agitation has already occured, this may escalate the behavior.
C. Confronting the client about the behavior
Rationale: This is not the priority nursing intervention because confronting the client may escalate their agitation.
References
Varcarolis, E. M., Fosbre, C. D., Chiappetta, L. (2021). Essentials of psychiatric-mental health nursing: A communication approach to evidence-based care. Elsevier.
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