A nurse is administering medications to a client who has dysphagia and a new prescription for divalproex sodium sprinkle capsules. Which of the following actions should the nurse take?

Choice A reason: Hallucinations are a common manifestation of delirium, especially when triggered by acute illness such as fever. Delirium is characterized by disturbances in attention, awareness, and cognition, often accompanied by perceptual disturbances like visual or auditory hallucinations.

Choice B reason: Agnosia, the inability to recognize objects or people, is more commonly associated with neurocognitive disorders such as dementia rather than acute delirium. While delirium affects cognition, agnosia is not a typical finding.

Choice C reason: Bradycardia is not a hallmark of delirium. Delirium is primarily a cognitive and perceptual disturbance, not a cardiac rhythm disorder. Bradycardia would suggest another underlying medical issue.

Choice D reason: Aphasia, a language disturbance, is more characteristic of stroke or other focal neurological disorders. Delirium may cause disorganized speech due to confusion, but not true aphasia.

Choice A reason: Informing the provider is necessary, but it is not the first action. Before contacting the provider, the nurse must gather immediate data to assess the severity of the client’s condition. Without objective information, communication with the provider may be incomplete or delayed in urgency.

Choice B reason: Obtaining a pulse oximetry reading is the priority because the client is experiencing shortness of breath and chest pain, which may indicate impaired oxygenation. Pulse oximetry provides rapid, non-invasive data about oxygen saturation, guiding immediate interventions. This step ensures that the nurse can quickly determine if supplemental oxygen or emergency measures are required.

Choice C reason: Administering pain medication is important for comfort, but pain management is not the priority when the client shows signs of possible respiratory compromise. Addressing oxygenation and circulation must come before pain relief in acute trauma situations.

Choice D reason: Requesting a chest x-ray is appropriate for diagnostic purposes, but it is not the first action. Imaging takes time and requires physician orders. Immediate assessment of oxygenation is more urgent to stabilize the client before further diagnostics.