A nurse is caring for a client who has a peripheral IV infusion and notes that the client's arm is edematous, cool, and tender at the catheter insertion site. Which of the following complications of IV therapy should the nurse suspect?

Choice A Reason:
Administering a prescribed oral dose of trazodone to the client is correct. Trazodone is sometimes used to manage agitation in patients with Alzheimer's disease, as it has calming effects and can help reduce agitation and anxiety. However, the use of any medication should be based on the client's individualized treatment plan and prescribed by a healthcare provider.
Choice B Reason:
Encouraging ambulation might not be suitable if the client is agitated, as it could potentially escalate the situation or increase the risk of falls or injury. Safety should be a priority, and ambulation might not be advisable during a state of agitation.
Choice C Reason:
Isolating the client in their room is incorrect. Isolating the client might increase feelings of confusion, fear, or distress, potentially worsening the agitation. It's important to engage and support the client rather than isolate them, which can be distressing for someone with Alzheimer's disease.
Choice D Reason:
Applying bilateral wrist restraints to the client is incorrect. The use of restraints should only be considered as a last resort when all other measures have failed and when there's an immediate risk of harm to the client or others. Restraints can be physically and psychologically harmful, leading to increased agitation, anxiety, and potential injury. They should be used only under strict guidelines and with proper authorization when all other interventions have been exhausted.

Choice A Reason:

Leave the television on in the client's room is incorrect. Leaving the television on doesn't directly address the safety concern of falls. While it might provide some distraction or comfort, it doesn't mitigate the risk of the client attempting to leave the bed unsafely.

Choice B Reason:

Raise all four side rails while the client is in bed is incorrect. Using all four side rails can be considered a form of restraint and is generally not recommended due to the risk of entrapment and potential psychological distress for the client. It can also increase the risk of agitation and attempts to climb over the rails, potentially resulting in falls.

Choice C Reason:

Move the overbed table away from the bed is incorrect. Moving the overbed table might reduce clutter around the bed area, but it doesn't directly address the risk of falls for a client with dementia. It's more about optimizing the environment than specifically addressing the safety concern related to the client's condition.

Choice D Reason:

Apply a motion sensor mat to the client's bed is correct. For an older adult with dementia at risk for falls, a motion sensor mat can be an effective safety measure. It alerts the staff when the client attempts to get out of bed, allowing for timely intervention to prevent falls. This helps the nursing staff respond promptly, ensuring the client's safety.