A nurse is collecting data from a client who has pernicious anemia.
The nurse should identify that which of the following findings increases the client's risk for injury?

Elevate extremity.Anticipated.This helps to reduce swelling and improve blood flow to the affected area. Send the catheter tip for culture.Anticipated.This helps to identify the possible cause of infection and guide the appropriate antibiotic therapy.

Assist in inserting a new IV catheter in a site distal to infiltration site.Contraindicated.A new IV catheter should be inserted in a site proximal to the infiltration site or in another extremity to avoid further damage to the infiltrated vein.

Suggest irrigating the IV catheter.Contraindicated.Irrigating the IV catheter may worsen the infiltration and increase the risk of complications.

Apply a cool compress to the extremity.Anticipated.This helps to reduce inflammation and pain at the infiltration site.

Administer phytonadione.Contraindicated.Phytonadione is a vitamin K antagonist that is used to reverse the effects of warfarin, an anticoagulant.It has no role in the management of IV infiltration.

Choice A rationale:

It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.

Choice B rationale:

Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.

Choice C rationale:

Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.

Choice D rationale:

Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.