A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

Choice A reason: Remeasuring confirms the 190/110 mm Hg reading, ensuring accuracy in kidney failure, where hypertension is common. It’s the first step before acting.

Choice B reason: Administering medication without verification risks error; BP may be inaccurate. In kidney failure, precise BP guides therapy, so this waits.

Choice C reason: Reporting to the charge nurse follows confirmation; unverified readings waste time. Accuracy in chronic kidney failure is critical before escalating.

Choice D reason: Bed rest may help, but confirming BP first prioritizes data. Kidney failure needs validated hypertension readings to direct immediate care safely.

Choice A reason: Meningococcal vaccine starts at 11-12 years, not infancy; three doses by kindergarten is incorrect. Scientifically, this misaligns with CDC schedules, as 2-month-olds get other vaccines (e.g., DTaP), showing misunderstanding of immunization timing.

Choice B reason: No feeding restriction exists for immunizations; fasting isn’t required. Scientifically, nutrition supports immune response, and this contradicts standard practice, as feeding doesn’t affect vaccine efficacy or safety, indicating a preparation misconception.

Choice C reason: High fever for 24 hours isn’t typical; mild fever may occur but not guaranteed. Scientifically, this exaggerates normal vaccine reactions (e.g., low-grade fever), misrepresenting expected immune responses, suggesting inaccurate outcome expectations.

Choice D reason: Rotavirus vaccine is oral at 2 months, per CDC schedule, aligning with its live attenuated form. Scientifically, this reflects correct administration knowledge, as it targets gut immunity, showing the guardian understands this immunization’s delivery accurately.