A client continues to report nausea following surgery from the anesthesia. She has received an antiemetic, and the next dose is not due for another hour. What should the nurse do first?

Choice A reason: Engaging the client in a walk and family discussion uses therapeutic communication and redirection, common in dementia care. This non-pharmacological approach validates emotions, reduces distress, and promotes calmness by shifting focus to positive memories, aligning with person-centered care principles to address emotional needs first.

Choice B reason: Alprazolam, a benzodiazepine, reduces anxiety but carries risks like sedation and falls in dementia patients. Pharmacological interventions should be secondary to non-pharmacological approaches, as they may exacerbate confusion or dependency. Addressing emotional distress through engagement is preferred before considering medications for anxiety management.

Choice C reason: Olanzapine, an antipsychotic, is used for severe agitation or psychosis in dementia. It poses risks like sedation, extrapyramidal symptoms, and increased mortality in elderly patients. Non-pharmacological interventions, like redirection, are prioritized to manage emotional distress safely, reserving medications for when behavioral approaches fail.

Choice D reason: Isolating the client in their room may increase distress and agitation in dementia patients, as it does not address their emotional needs. Social isolation can worsen confusion and feelings of abandonment. Therapeutic engagement, such as redirection or validation, is more effective in calming the client and fostering trust.

Choice A reason: Mild itching may indicate a minor allergic reaction to a transfusion, caused by sensitivity to donor plasma proteins. While concerning, it is not immediately life-threatening and can often be managed with antihistamines. Severe symptoms like fever and chills take priority, as they suggest more dangerous reactions like hemolytic or febrile responses.

Choice B reason: A slight increase in heart rate can occur due to anxiety or fluid volume changes during transfusion but is not specific to a transfusion reaction. It is less urgent than fever and chills, which indicate a potentially severe reaction like hemolysis or infection, requiring immediate cessation of the transfusion.

Choice C reason: Sudden chills and fever during a transfusion suggest a febrile non-hemolytic reaction or, more critically, a hemolytic reaction or sepsis. These can cause systemic inflammation, hemolysis, or shock, requiring immediate stopping of the transfusion, assessment, and intervention to prevent life-threatening complications like renal failure or disseminated intravascular coagulation.

Choice D reason: Minor redness at the IV site may indicate local irritation or phlebitis, not a systemic transfusion reaction. It is less urgent than systemic symptoms like fever and chills, which signal severe reactions requiring immediate action. Local symptoms can be monitored and managed without stopping the transfusion.