A nurse is contributing to the plan of care for a client who has AIDS and has malnutrition. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:

LDL (Low-Density Lipoprotein) is incorrect. This is a type of cholesterol and is not specifically monitored in relation to warfarin therapy.

Choice B Reason:

INR (International Normalized Ratio) is correct. Warfarin is an anticoagulant medication, and its dosage needs to be adjusted based on the INR levels. INR monitoring helps assess the clotting tendency of the blood and ensures that the dosage of warfarin is within the therapeutic range to prevent blood clots without causing excessive bleeding.

Choice C Reason:

BUN (Blood Urea Nitrogen) is incorrect. This value is primarily used to assess kidney function and is not directly related to monitoring warfarin therapy.

Choice D Reason:

Hct (Hematocrit) is incorrect. This measures the percentage of red blood cells in the blood and is not directly related to monitoring warfarin therapy for atrial fibrillation.

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.