A nurse is caring for an elderly patient with advanced dementia who is unable to make healthcare decisions independently. The patient’s adult child has been appointed legal guardian. What is the nurse’s best action regarding the patient’s care decisions?

Choice A reason: Tangential thinking involves shifting topics without returning to the original point, common in schizophrenia or mania. It reflects disorganized thought processes due to impaired prefrontal cortex function, leading to irrelevant responses, making this the correct choice for the described speech pattern.

Choice B reason: Circumstantial thinking involves excessive detail but eventually returns to the original point. The scenario describes never returning to the question, indicating a more disorganized process than circumstantiality, making this choice incorrect for the patient’s speech pattern.

Choice C reason: Flight of ideas involves rapid topic shifts driven by associations, often in mania. While similar, it is less aimless than tangentiality, which does not return to the original topic, making this choice less precise for the described behavior.

Choice D reason: Concrete thinking involves literal interpretations without abstract reasoning, common in cognitive impairments. The scenario describes topic-shifting, not literal thinking, making this choice incorrect, as it does not address the disorganized speech pattern observed.

Choice A reason: Leaving a restrained patient unattended for 2 hours violates safety standards, as restraints pose risks like injury or respiratory compromise. Regular monitoring is required to assess circulation, skin integrity, and psychological distress, ensuring patient safety, making this choice incorrect.

Choice B reason: Restraining all four limbs tightly risks injury, such as nerve damage or impaired circulation, and violates least-restrictive restraint principles. Restraints should allow minimal movement and be applied only as necessary, with regular reassessment, making this choice incorrect.

Choice C reason: A provider’s face-to-face evaluation within 1 hour is required by regulations to ensure restraints are justified and safe. This assesses the patient’s condition, mental status, and need for continued restraint, minimizing harm and ensuring compliance, making this the correct choice.

Choice D reason: Documenting restraint use only at shift’s end is inadequate, as regulations require ongoing documentation of restraint rationale, patient condition, and monitoring. Delayed documentation risks missing critical changes, compromising care and legal compliance, making this choice incorrect.