Cognitive Reflection Test (CRT) Practice

What action should the nurse take for an older adult client who is agitated and confused?

1. Leave the client alone to calm down

2. Assign the nursing assistant to stay with the client

3. Strap the client to the bed for safety

4. Introduce distractions to divert the client

The correct answer is: Assign the nursing assistant to stay with the client

The most appropriate action for a nurse to take when dealing with an older adult client who is agitated and confused is to assign a nursing assistant to stay with the client. This approach provides immediate support and supervision, allowing the client to feel more secure and less isolated. Having someone present can help monitor the client's behavior and well-being, ensuring their safety while calming them. In situations of agitation and confusion, it is crucial to provide reassurance and maintain a safe environment. Close observation can also assist in identifying any underlying issues contributing to the client's distress and facilitate effective intervention. Introducing distractions can be helpful, but it may not address the immediate need for supervision and support. Leaving the client alone might lead to increased anxiety or risk of injury. Restraining a client, such as strapping them to the bed, is not only ethically questionable but can also exacerbate feelings of fear and agitation. Thus, assigning a nursing assistant to provide companionship is the safest and most supportive choice in this scenario.