A nurse in an emergency department is assessing a client who was brought in by a caregiver. The caregiver reports that the client has had a change in behavior over the past 2 days. The nurse should identify which of the following findings as an indication that the client has delirium?
Select all that apply.

Choice A reason: Allowing the client to eat in their room is not appropriate because clients with anorexia nervosa often isolate themselves and may attempt to avoid eating or hide food. Supervised meals in a communal or monitored setting are necessary to ensure adequate intake and prevent food avoidance behaviors.

Choice B reason: Obtaining vital signs only once per day is insufficient. Clients with anorexia nervosa are at risk for severe complications such as bradycardia, hypotension, hypothermia, and electrolyte imbalances. Frequent monitoring is required to detect early signs of medical instability. Once daily vital signs would miss important changes.

Choice C reason: Weighing the client daily after the first voiding is the correct intervention. This ensures consistency and accuracy in monitoring weight trends, as voiding eliminates the variable of bladder volume. Daily weights are essential for tracking progress, evaluating treatment effectiveness, and identifying rapid changes that may indicate medical risk.

Choice D reason: Allowing the client to determine their daily calorie intake is inappropriate because individuals with anorexia nervosa often severely restrict calories. Nutritional intake must be carefully planned and supervised by the healthcare team to promote gradual weight restoration and prevent refeeding syndrome.

Choice A reason: Identifying the client’s feelings underlying the delusions is therapeutic. Delusions often mask fear, anxiety, or insecurity. By focusing on the emotions rather than the false belief, the nurse validates the client’s experience without reinforcing the delusion. This approach builds trust and supports emotional regulation.

Choice B reason: Telling the client that the delusion is not real is ineffective and can increase defensiveness. Clients with schizophrenia often lack insight, and direct confrontation may escalate agitation or mistrust.

Choice C reason: Reinforcing the delusion is harmful. It strengthens false beliefs and impedes recovery. Nurses must avoid validating delusional content while still supporting the client’s emotional needs.

Choice D reason: Helping the client ignore events that trigger delusions is unrealistic. Triggers cannot always be avoided, and ignoring them does not teach coping strategies. Instead, nurses should help clients develop grounding techniques and reality-based coping skills.