A nurse is preparing to administer cefaclor to a preschooler who weighs 20 kg. The child is to receive cefacior 30 mg/kg/day to divide equally every 8 hr. Available is cefacior suspension 125 mg/5 mL. How many mL should the nurse administer for one dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A. Ecchymosis in the exposed portion of the left foot: Bruising may occur with the initial injury or minor trauma but is not a reliable early indicator of compartment syndrome. Ecchymosis does not reflect the elevated pressure within the fascial compartment that compromises circulation and nerve function.

B. Inability to move the left foot: Motor deficits, such as inability to move the toes or foot, indicate nerve compression and ischemia within the compartment. This is a late but critical sign of compartment syndrome, requiring immediate evaluation to prevent permanent damage.

C. Paresthesia in the left foot: Tingling, numbness, or “pins and needles” sensation is an early sign of nerve ischemia caused by increased compartment pressure. Paresthesia often precedes motor deficits and is an important symptom for early recognition and intervention.

D. Pallor in the exposed portion of the left foot: Pale skin indicates compromised arterial blood flow resulting from elevated intracompartmental pressure. Pallor reflects ischemia and is a classic clinical sign of compartment syndrome requiring urgent intervention.

E. Increased warmth of the exposed portion of the left foot: Compartment syndrome usually causes decreased perfusion, leading to cool or cold extremities rather than warmth. Increased warmth is more commonly associated with infection or inflammation, not compartment syndrome.

A. Place the client in restraints: Physical restraints are used only as a last resort when the client poses an immediate danger to self or others. In delirium, restraints can worsen agitation, increase confusion, and elevate the risk of injury or further cognitive decline. Nonpharmacologic de-escalation and environmental modifications are preferred initial interventions.

B. Offer the client a variety of activities to choose from: Clients with delirium have impaired attention, fluctuating levels of consciousness, and reduced ability to process multiple stimuli. Providing numerous choices can increase confusion and cognitive overload. Care should focus on structured, simple activities rather than offering multiple options.

C. Communicate with the client using simple, direct statements: Delirium impairs cognition, attention, and comprehension, making complex communication difficult. Using short, clear, and direct statements helps reduce misinterpretation and supports orientation. Consistent, simple communication decreases anxiety and promotes better understanding in hallucinations.

D. Limit how often the client's partner can visit: Familiar individuals can provide reassurance, assist with reorientation, and decrease anxiety in clients with delirium. Restricting visits may increase confusion and agitation. Encouraging the presence of trusted family members often supports cognitive stabilization and emotional comfort.