Difficulty: Medium
Average Score: 95%
Simulated
Passage / Scenario
A client with dementia who is agitated and having difficulty staying in his chair.A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?
Correct answer
C
Rationale
The correct answer is C: Place a seat alarm in the client's chair. This is the best initial intervention as it promotes safety by alerting the nurse when the client attempts to leave the chair, preventing falls. Applying a vest restraint (choice A) should be avoided as it restricts the client's movement and dignity. Placing the client in bed with raised side rails (choice B) may worsen agitation and increase the risk of falls. Administering lorazepam (choice D) should not be the first choice as it is a sedative that may not address the underlying cause of agitation and can have adverse effects in older adults.