A nurse is caring for a client who has a prescription for furosemide, which of the following laboratory tests should the nurse monitor?

Rationale:

• Past medical history like Parkinson’s disease increases the risk of delirium but is not a direct symptom. It may contribute but does not confirm the presence of delirium alone. Current behavior and cognition changes are more reliable indicators.

• Illusions involve misinterpreting real stimuli, unlike this client’s perception of spiders that aren’t there. Hallucinations are a more accurate description of this experience. Therefore, illusions are less consistent with the actual findings.

• Change in orientation is a hallmark of delirium and is shown by the client’s confusion about the date and location. The sudden onset and fluctuation in awareness suggest an acute cognitive disturbance. This finding supports the development of delirium in the ICU setting.

• Hallucinations, such as seeing spiders that are not present, reflect sensory misperceptions. These are typical in hyperactive delirium and often cause agitation or fear. They indicate an altered mental state requiring urgent assessment.

Rationale:

A. Inform the caregiver that it is okay to use the same towels: Sharing towels can spread impetigo, which is a highly contagious bacterial skin infection. Families should be instructed to use separate towels, washcloths, and linens to reduce the risk of cross-contamination.

B. Request the provider to prescribe an antiviral medication: Impetigo is caused by bacteria such as Staphylococcus aureus or Streptococcus pyogenes, not viruses. Antibacterial agents, not antivirals, are the appropriate treatment for managing this condition.

C. Place the toddler on droplet precautions: Impetigo primarily spreads through direct contact with lesions or contaminated objects, not respiratory droplets. Standard precautions with contact isolation are typically used rather than droplet precautions.

D. Prevent the toddler from scratching their skin by using elbow restraints: Scratching can worsen impetigo lesions and lead to further bacterial spread or secondary infection. Using soft restraints like elbow splints can safely discourage scratching and promote healing while preventing the infection from spreading.