A charge nurse is evaluating a newly licensed nurse's electronic documentation for several clients. Which of the following entries for medication doses should the charge nurse identify as correct?

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

Rationale:

A. Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: CBC results are general health data and not considered sensitive. In most jurisdictions, parents of minors typically have access to such information unless restricted by specific laws or agreements.

B. Reviewing the results of the client's urinalysis with their parents, without the client's consent: Urinalysis is typically used for general health screening or to assess conditions like infections or kidney issues. Unless it's linked to drug testing or STI diagnosis, sharing these results with parents is not considered a breach.

C. Reviewing the results of the client's celiac screening with their parents, without the client's consent: Celiac screening relates to a chronic gastrointestinal condition and is not categorized as confidential reproductive or mental health information. Sharing it with parents does not typically violate confidentiality.

D. Reviewing the results of the client's chlamydia screening with their parents, without the client's consent: Reproductive and sexual health services, including STI screening, are protected under minor consent laws in many regions. Disclosing this information without the adolescent's permission breaches their legal right to confidentiality.