A nurse is assisting with the plan of care for10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?

A) Weight loss: Weight loss is not a sign of fluid overload; rather, it is more indicative of dehydration or insufficient nutritional intake. Fluid overload typically leads to weight gain due to the accumulation of excess fluid in the body, so weight loss would not be a manifestation of this condition.

B) Decreased skin turgor: Decreased skin turgor is a common sign of dehydration, not fluid overload. When a person is dehydrated, the skin loses its elasticity, and it takes longer to return to its normal position after being pinched. This is the opposite of what is seen in fluid overload, where excess fluid causes the skin to appear more swollen or taut.

C) Decreased blood pressure: Decreased blood pressure is more commonly associated with hypovolemia (low fluid volume) or dehydration, rather than fluid overload. In fluid overload, blood pressure may actually rise due to the increased volume of circulating blood, not decrease.

D) Crackles heard in the lungs: Crackles, or rales, heard in the lungs are a classic sign of fluid overload, particularly when the excess fluid accumulates in the lungs (pulmonary edema). This can occur due to the heart's inability to pump effectively, leading to fluid retention in the lungs. Therefore, crackles in the lungs are a key manifestation of fluid overload.

A) "Individuals who have this disorder have a flat affect.": A flat affect, which refers to a lack of emotional expression, is more characteristic of conditions like depression or schizophrenia rather than delirium. Delirium typically involves fluctuating levels of consciousness, confusion, and altered attention, but a flat affect is not a defining feature.

B) "This disorder is characterized by a sudden onset of mental confusion.": This statement is correct. Delirium is characterized by a rapid onset of symptoms, including confusion, disorientation, and changes in cognition. The acute nature of delirium distinguishes it from other conditions like dementia, which develops gradually over time.

C) "Individuals who have this disorder speak at a slow pace.": While some individuals with delirium may speak slowly due to confusion or disorientation, this is not a defining characteristic of the disorder. Delirium can cause a variety of speech patterns, including rambling, incoherence, or even rapid speech depending on the individual’s cognitive state.

D) "This disorder is not reversible.": This statement is incorrect. Delirium is typically reversible if the underlying cause (such as infection, dehydration, or medication side effects) is identified and treated. Unlike progressive disorders like dementia, delirium can often be resolved with appropriate medical intervention.