A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

A. Incoordination, such as clumsiness or difficulty walking, can be an early sign of lithium toxicity. It reflects the neurological effects of elevated lithium levels on motor coordination.
B. Polyuria (excessive urination) is a common late symptom of lithium toxicity. Lithium interferes with the kidney's ability to concentrate urine, leading to increased urine output.
C. Nausea is a gastrointestinal symptom that can occur in the early stages of lithium toxicity. It is often accompanied by other gastrointestinal disturbances such as vomiting and diarrhea.
D. Convulsions (seizures) are not typically considered early manifestations of lithium toxicity but rather indicate severe toxicity. Seizures can occur at higher levels of lithium toxicity and require immediate medical intervention.
E. Confusion is another early sign of lithium toxicity. It reflects the impact of elevated lithium levels on the central nervous system, leading to cognitive impairment and altered mental status.

A. Obsessive behaviors, such as repetitive actions or fixations on specific thoughts or tasks, can be indicative of delirium. Delirium often manifests with altered behavior patterns that are unusual for the individual, including obsessive or compulsive-like behaviors that are not typical of their baseline mental status. However, this is not specific to delirium.
B. Fluctuating orientation, where the client is sometimes alert and oriented and at other times confused or disoriented, is a hallmark of delirium. Unlike dementia, which typically presents with a more steady decline in cognitive function, delirium is characterized by rapid changes in mental status over hours to days. This fluctuation is important to note as it strongly suggests delirium rather than other chronic cognitive impairments.
C. Gradual memory loss reported by family members is more suggestive of chronic conditions such as dementia rather than delirium. Delirium, in contrast, is characterized by acute onset and fluctuating course rather than a gradual decline in cognitive abilities over time.
D. Depression can coexist with delirium, but a consistent state of depression without acute changes in mental status is less indicative of delirium. Delirium is characterized by rapid changes in cognition and behavior rather than a persistent mood disorder. Therefore, while depression should be assessed and managed appropriately, it is not typically a sign of delirium unless there are acute changes in mental status accompanying it.