An eighty-five-year-old man was admitted for surgery for benign prostatic hypertrophy. Preoperatively he was alert, oriented, cooperative, and knowledgeable about his surgery. Several hours after surgery, the evening nurse found him acutely confused, agitated, and trying to climb over the protective side rails on his bed. The most appropriate nursing intervention that will calm an agitated client is:
A. Speak soothingly and provide quiet music
B. Encourage family phone calls
C. Limit visits by staff
D. Position in a bright, busy area
Correct Answer: A. Speak soothingly and provide quiet music
The environment is an important factor in the prevention of injuries. Talking softly and providing quiet music have a calming effect on the agitated client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. Client develops a feeling of security in the presence of a calm staff person.
Option B: Phone calls from his family will not help a client who is trying to climb over the side rails and may even add to his danger. Therapeutic skills need to be directed toward putting the client at ease, because the nurse who is a stranger may pose a threat to the highly anxious client.
Option C: The client needs frequent visits by the staff to orient him and to assess his safety. The client’s safety is utmost priority. A highly anxious client should not be left alone as his anxiety will escalate.
Option D: Putting the client in a bright, busy area would probably add to his confusion. Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked.