A nurse is assisting with the care of a client who last used heroin 8 hr ago. Which of the following findings should the nurse identify as a manifestation of opioid withdrawal?

A. Fats: While fats provide energy and help with cell membrane structure, they are not the primary nutrient required to promote wound healing. Excess fat intake without proper balance may not directly aid in faster tissue repair.

B. Calcium: Calcium is important for bone health and muscle function but does not play a central role in soft tissue wound healing. It is more critical in fracture healing rather than open wound repair.

C. Vitamin D: Vitamin D supports calcium absorption and bone health. Although it contributes to immune function, it is not the main nutrient needed to directly repair skin and soft tissue wounds.

D. Protein: Protein is essential for wound healing because it supports cell growth, tissue repair, and immune function. Adequate protein intake is critical to form new tissue, promote collagen synthesis, and restore skin integrity in clients with open wounds.

A. Encourage visits from family members: While family presence can help reduce anxiety and reorient clients with delirium, it is not the immediate first step. Before implementing supportive strategies, the nurse must first assess the client’s neurological status to determine the severity and possible cause of the delirium.

B. Administer an anxiolytic medication: Administering medications should not be the first action because delirium can be caused by multiple reversible factors. Sedating a client without identifying the underlying cause may worsen confusion or mask important symptoms that need immediate intervention.

C. Determine the client's level of consciousness: Assessing the client’s level of consciousness is the priority because it provides critical information about the severity of the delirium and helps guide immediate and appropriate interventions. Early assessment ensures that life-threatening conditions, such as hypoxia or sepsis, are not overlooked.

D. Keep lights on in the client's room: Maintaining a well-lit environment can help prevent disorientation, especially at night, but it is a secondary supportive measure. Assessment of mental status must occur first to prioritize safety and identify urgent medical needs.