A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.

B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.

C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.

D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical

incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.

A. Echolalia, or repeating the words of others, can be a manifestation of schizophrenia.

B. Word salad, or a jumble of incoherent words and phrases, can occur in schizophrenia.

C. Expressing interest in ADLs is not typically associated with schizophrenia and may indicate a different mental health state.

D. A blunt affect, or reduced emotional expression, is a common symptom of schizophrenia.

E. Delusions, or fixed false beliefs, are a hallmark symptom of schizophrenia.