An older woman who receives intravenous (IV) fluids is making ...

[imowrer]

An older woman who receives intravenous (IV) fluids is making wide gesticulations with her arms and loudly insulting the nursing staff. Which intervention should the nurse implement to maintain safe, effective nursing care initially?
 
  a. Apply bilateral upper extremity restraints.
  b. Administer haloperidol (Haldol) for agita-tion.
  c. Close the door to her room to reduce the noise.
  d. Determine the patients needs.

Question 2

An older male adult is taking ziprasidone (Geodon), and the nurse helps him to choose menu items. To prevent exacerbation of potential adverse effects of therapy, which menu item does the nurse instruct the man to avoid?
 
  a. Biscuits and gravy
  b. Coffee with cream
  c. Whole grain bread
  d. Mixed green salad

[JaynaD87]

Answer to Question 1

D
To help maintain her independence and permit the administration of IV fluids yet provide safe, effective care, the nurse should determine what the patient is attempting to convey and then ad-dress those needs. Restraining one side creates a potential threat from the other arm to the inte-grity of the IV, but bilateral restraints can be justified for the protection of the IV site. However, as a first step, the nurse should determine if the patient has a need that has not been met before moving to a restraint.
Administering an antipsychotic agent can be justified for agitation but not in this patient. Less intrusive measures are available for initial protective measures. Although nurses tend to keep the doors of patients' and residents' rooms slightly ajar to maintain privacy, closing this woman's door is contraindicated to control noise because it can contribute to the risk of falls and injury and does nothing to maintain the integrity of the IV.

Answer to Question 2

B

Feedback
A Incorrect. The nurse instructs all older adults to avoid eating biscuits and gravy because these items have an excessively high fat content.
B Correct. Because antipsychotic medications potentially impair the body's ther-moregulatory ability, the nurse instructs an older adult who takes an antipsy-chotic agent like ziprasidone to avoid caffeinated beverages because they con-tribute to dehydration. This man is at high risk for organ damage due to hyper-thermia from mild elevations in the environmental temperature; so, he must avoid dehydration, stay in cool temperatures, keep out of direct sunlight, and alert people around him and caregivers to monitor his temperature carefully and to be prepared to provide cooling sponge baths, cool liquids, and other measures to reduce his temperature quickly.
C Incorrect. Whole grain bread is a healthy food item to choose.
D Incorrect. Mixed green salad is a healthy food item to choose.