A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time?

Question

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Alzheimer disease (AD) is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (eg, agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (eg, constipation) or eating (eg, inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs (Option A). Maslow hierarchy of needs (Option B) Environmental stressors (eg, excessive noise, overstimulation) may cause behavioral changes such as agitation or restlessness in clients with AD and should be addressed after intervening to meet the client's basic needs. (Option C) Caregiver support is essential to client care, especially in the home health environment. After addressing the client's needs, the nurse should provide information about community support groups, respite care, and adult day care to help reduce caregiver fatigue. (Option D) The nurse should use behavioral-management techniques (eg, reassurance, distraction, redirection) to assist with deescalation. However, the nurse must assess for and address sources of agitation first. Educational objective: When caring for a client with Alzheimer disease who has increasing or persistent behavioral changes, the nurse should first assess for possible physical stressors such as pain or problems with elimination or eating.

A Home Health Nurse Visits a Client with Alzheimer Disease