A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Choice A reason:

Isolating a client with Alzheimer's disease in their room can exacerbate feelings of confusion, agitation, and loneliness. Social isolation is linked with an increased risk of developing dementia and can worsen existing symptoms. It is important to provide a supportive environment that includes social interaction and engagement.

Choice B reason:

Administering trazodone, an antidepressant, can be effective in managing behavioral symptoms in dementia patients, including agitation. However, it should be used cautiously and as part of a comprehensive care plan that prioritizes non-pharmacological interventions first. Trazodone can help improve sleep quality and, indirectly, cognitive function.

Choice C reason:

The use of physical restraints, such as bilateral wrist restraints, is highly discouraged in dementia care due to the potential for serious harm, including physical and psychological distress, decreased mobility, and increased risk of injury. Restraints can lead to a loss of independence and self-esteem and should be avoided.

Choice D reason:

Encouraging a client with Alzheimer's disease to ambulate with a staff member can provide numerous benefits. Regular physical activity is crucial for maintaining muscle strength, enhancing circulation, and promoting overall wellness. It can also stimulate cognitive functions and reduce the risk of depression and social isolation. Ambulation with assistance ensures safety and provides an opportunity for social interaction and environmental orientation, which can help reduce agitation.

Choice A reason:
Using the client's left arm to obtain blood samples is the correct action to prevent lymphedema after a right radical mastectomy. Lymphedema can occur when the lymphatic drainage is disrupted, which is a risk after mastectomy involving lymph node removal. To reduce this risk, it is recommended to avoid procedures such as blood draws and blood pressure measurements on the affected side.

Choice B reason:
Obtaining blood pressure readings using the client's right arm, the side of the mastectomy, is not recommended. This action can increase the risk of lymphedema due to the pressure applied during the measurement, which can impede lymphatic flow and contribute to fluid accumulation.

Choice C reason:
Keeping both arms below the level of the client's heart is not specifically related to the prevention of lymphedema. While elevation of the affected arm can help promote lymphatic drainage and reduce swelling, there is no recommendation to keep both arms below heart level as a standard practice.

Choice D reason:
Limiting range-of-motion exercises with the affected arm is not advised as a means to prevent lymphedema. In fact, gentle range-of-motion exercises are encouraged postoperatively to prevent stiffness and improve mobility. However, these exercises should be performed carefully and gradually to avoid overexertion, which could lead to lymphedema.