A client who is agitated is gesturing at the television in the day room and talking to an empty chair. Which interventions should practical nurse (PN) implement? Select all that apply.

A. Episodes of vertigo and loss of balance: These findings are more commonly associated with vestibular or neurological disorders rather than IV fluid complications. They do not directly indicate fluid overload or electrolyte imbalance from normal saline infusion.

B. Fatigue and breathlessness upon exertion: These symptoms suggest fluid volume excess, which can occur when IV fluids accumulate faster than the body can handle. Older adults are especially prone to heart failure and pulmonary congestion, leading to dyspnea and generalized fatigue from decreased oxygen exchange.

C. Apical pulse rate of 64 beats/minute: A pulse rate within this range is normal for many adults and does not indicate fluid imbalance or overload. It reflects a stable cardiovascular status rather than a complication of IV therapy.

D. Average 24-hour urinary output of 1,400 mL: This urinary output is within normal limits for an adult (about 30 mL/hour minimum). It indicates adequate renal function and does not signal fluid overload or retention related to IV therapy.

A. Explain daily schedule of unit activities: Introducing the unit’s schedule too early may overwhelm a paranoid client who is already fearful and withdrawn. The client first needs to establish a sense of safety and trust before being able to process details about daily routines.

B. Offer the client an as needed (PRN) medication: Administering medication without assessing the client’s readiness to communicate or identifying signs of distress is premature. PRN medications should only be offered when clinically indicated and after therapeutic approaches have been attempted.

C. Describe functions of the practical nurse (PN): Explaining the PN’s role is the best initial action because it reduces the client’s anxiety and suspicion. Paranoid clients often feel threatened by unfamiliar individuals, so calmly explaining your role helps establish trust, clarify intent, and promote engagement in care.

D. Review client rights of hospitalization: Although reviewing client rights is important, it is not the priority when first approaching a paranoid client. Discussing rights before rapport is established may be perceived as intimidating or confusing, further increasing the client’s withdrawal or fear.