A client sustained a head injury when hit by lead pipe two hours ago and is admitted for observation after the computerized tomography (CT) scan indicates that no spinal cord injury and no skull fractures are present. When the client begins projectile vomiting, the nurse quickly turns the client's head to the side and administers ondansetron 4 mg IV as prescribed. Reassessment indicates that the client's Glasgow coma score is 13 and the left pupil is dilated without reaction to light. Which intervention(s) should the nurse implement? Select all that apply.

Rationale for Correct Answers:

• Delirium: The client shows sudden confusion, difficulty remembering events, disorientation to time and place, and inconsistent attention span. These symptoms developed acutely after surgery, indicating delirium rather than dementia or depression, which have slower onset and different characteristics.
• Institute fall precautions: Delirium increases fall risk due to confusion, impaired judgment, and unawareness of physical limitations. This client has already shown poor safety awareness (e.g., forgetting what a call light is), making fall precautions essential.
• Reorient to environment: Repeated verbal reminders of place, time, and situation help reduce confusion and anxiety in delirious patients. The client is unsure why she is hospitalized and forgets instructions, making reorientation a key nursing strategy.
• Nutritional intake/intake and output: The client is eating poorly and has signs of dehydration (dry mucosa, tenting). Monitoring intake and output supports correction of fluid/electrolyte imbalances, which can worsen delirium if untreated.
• Drug therapy: Older adults are more sensitive to medication side effects, especially those that affect cognition. Monitoring the effects of prescribed drugs is crucial since inappropriate or excessive medication can contribute to or worsen delirium.

Rationale for Incorrect Answers:

• Dementia: Dementia presents as a chronic, progressive decline in cognitive function. The client’s confusion is recent, fluctuates, and appeared postoperatively, which is not consistent with the gradual, irreversible decline typical of dementia.
• Depression: While older adults may have decreased appetite or low energy due to depression, the client’s acute confusion, memory loss, and inability to perform familiar tasks point more strongly toward delirium rather than mood-related impairment.
• Remove all objects that could cause harm: While this may be helpful in some situations, the client is not displaying aggressive behavior or intentional self-harm. Delirium management focuses more on supervision, reorientation, and safety support.
• Family involvement: While helpful in long-term care, family involvement is not the most immediate or measurable parameter in evaluating acute delirium. The priority is physiologic stabilization and cognitive assessment.
• Intracranial pressure: There is no evidence of increased ICP (e.g., no severe headache, vomiting, pupil changes). Delirium is more likely due to metabolic or environmental factors, not intracranial pressure elevation in this context.

Convert the client's weight from pounds to kilograms:

Weight (kg) = Weight (pounds) / 2.2 pounds/kg

= 160 pounds / 2.2 pounds/kg

≈ 72.73 kg

Calculate the total daily dose in milligrams:

Total daily dose (mg) = Prescribed dose (mg/kg/day) x Client's weight (kg)

= 5 mg/kg/day x 72.73 kg

≈ 363.65 mg/day

Determine the number of doses per day:

Number of doses per day = 24 hours / Frequency of doses (hours)

= 24 hours / 8 hours/dose

= 3 doses/day

Calculate the dose to administer with each dose:

Dose per administration (mg) = Total daily dose (mg) / Number of doses per day

= 363.65 mg / 3 doses

≈ 121.22 mg

Round to the nearest whole number:

= 121 mg