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:

Flight of ideas is a symptom characterized by an abrupt switch from one topic to another in a very fast manner. It's commonly seen in manic episodes of bipolar disorder rather than schizophrenia.

Choice B reason:

Erotomania is a type of delusional disorder where the affected person believes that another person, often someone important or famous, is in love with them. This does not align with the behavior described in the scenario.

Choice C reason:

Delusions of grandeur involve an exaggerated belief of one's importance, power, knowledge, or identity. They are often found in narcissistic personality disorder and various types of psychosis, including schizophrenia. However, the behavior in the scenario does not indicate delusions of grandeur but rather a misinterpretation of others' actions.

Choice D reason:

Ideas of reference involve the belief that casual incidents and other external events have a particular and unusual significance that is specific to the person. This is consistent with the client's reaction to the group's laughter as being directed at them personally, which is why it is the correct answer.

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.