A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

A) Administer PRN haloperidol IM to the client:

Administering haloperidol is not the first-line intervention for managing behavioral disturbances in clients with dementia, especially in response to acute agitation. While antipsychotic medications like haloperidol may be prescribed in some cases, they should be used judiciously due to the risk of adverse effects, particularly in elderly clients. Additionally, administering medication should not be the first action taken without attempting non-pharmacological interventions.

B) Engage the client in a repetitive activity as a distraction:

This is the most appropriate initial intervention when dealing with an agitated client with dementia. Engaging the client in a repetitive, calming activity can help redirect their focus and reduce agitation. Simple, familiar tasks or activities tailored to the client's preferences can be effective in providing comfort and reducing distress.

C) Apply wrist restraints to the client:

Using physical restraints should be avoided unless absolutely necessary for the safety of the client or others. Restraints can cause physical and psychological harm, increase agitation, and compromise the client's dignity and autonomy. Therefore, restraint use should be a last resort and implemented only after other interventions have been attempted and deemed ineffective or when there is an imminent risk of harm.

D) Place the client in a seclusion room:

Seclusion should not be used as an initial intervention for managing agitation in clients with dementia. Seclusion can exacerbate distress and increase feelings of isolation and fear, which may escalate agitation further. It should only be considered as a last resort for managing severe agitation or aggression when all other interventions have failed and there is a risk of harm to the client or others.

Answer: C

Rationale:

C) "It sounds like you have concerns about the procedure."
This response is therapeutic and encourages the client to express their concerns, allowing the nurse to understand the client's feelings without judgment. It opens up a supportive dialogue where the client can discuss their fears, anxieties, or misconceptions about the colostomy, which can then be addressed appropriately.

A) "Why have you decided not to have the procedure?"
This response can come across as confrontational and might make the client feel defensive or pressured to justify their decision, which is not conducive to a therapeutic conversation.

B) "Don't worry. You will adjust to the colostomy quickly."
This statement dismisses the client's current feelings and concerns. Telling the client not to worry minimizes their emotional experience and may make them feel misunderstood or invalidated.

D) "Do you think that's the right decision for you and your family?"
This response introduces external pressure by involving the family and shifts the focus away from the client’s personal feelings and autonomy, which could increase their anxiety about making a decision.